Inspection·June 24, 2022

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 out of 38 sampled residents (Resident #357) was free from restraints. The facility had a census of 299 residents during the survey. Residents Affected - Few The findings included: Observation of Resident #357 on 06/20/22 at 07:34 AM revealed the resident in bed with a hand mitten on her left hand. The hand mitten was white, had a mesh covering the residents hand and had a padded surface where the residents palm rested. The hand mitten wasn't tied, but it was closed around the wrist. The resident was in a low bed, had Isosource 1.5cal, at 50cc/hr (hour), 552cc(cubic centimeters) had infused. The resident was observed to be able to move her left arm. The resident was not observed to move her right arm. Observation on 06/21/22 at 08:45 AM, Resident #357 was in a low bed, awake, Isosource 1.5cal at 50cc/hr, 100 cc had infused. The resident did not have the hand mitten on her left hand. The resident was observed moving her left hand around, touching her face, and rubbing her fingers together. The residents right arm was covered with a blanket, and the resident wasn't observed to move the right arm. Observation on 06/23/22 at 08:16 AM, Resident #357 was observed in a low bed, awake, her gown was partially off her shoulders. Staff U, a Certified Nursing Assistant was in the room. Staff U reported, resident #357 pulls her gown off and pulls at things. The resident had Isosource 1.5 cal at 45 cc/hr. The resident did not have the mitten on her left hand. The residents right arm was not observed to move. Staff U fixed the residents gown on her shoulders. The resident was observed taking off gown. During record review it was revealed, Resident #357 was admitted to the facility on [DATE]. The residents diagnoses included but were not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Generalized Anxiety Disorder, Type 2 Diabetes Mellitus and Encounter for Attention to Gastrostomy. During record review it was noted the residents Minimum Data Set (MDS) was in progress. During record review it was noted on 6/21/22 a Psychiatric Evaluation was completed by the Advanced Registered Nurse Practitioner. The evaluation documents the resident is showing signs of episodic anxiety disorder. During record review, there was no physicians order for the use of the hand mitten. The residents medical record included the following Care Plans: Resident at risk for falls Resident at risk for skin breakdown Resident at risk to experience pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 2 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 0604 Resident/Family wishes resident to return home after therapy completed Level of Harm - Minimal harm or potential for actual harm Potential for altered psychosocial well being r/t (related to) restriction on visitation Residents Affected - Few Resident has PEG (Percutaneous Endoscopic Gastrostomy) tube for nutrition and Dysphagia at risk for complications Resident has a potential for isolation and low activity participation Resident has no Advance Directives on records Resident has potential for nutritional and hydration deficits During interview on 06/24/22 at 09:07 AM, Staff I, the Registered Nurse for Resident #357 on 6/20/2022, acknowledged the resident had a mitten on possibly because of the resident pulling on her G (Gastrostomy) tube. She reports, she removed it and said, she would monitor her every 2 hours. During the review of the facility's policy and procedure titled, Use of Restraints dated Revised January 2022. The policy statement included, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsucessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The Policy Interpretation and Implementation included: 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri chairs, and lap cushion and trays that the resident cannot remove. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 3 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Observation on 6/21/22 at 1:04 PM revealed Resident #284 in her room in bed. Resident #284's left arm was in a sling restricted use of the arm. The call light was attached to the bed linens on her left side. The bed was in a low position and there was a mat on the floor to her left side. Observation on 6/22/22 at 10:20 AM revealed Resident #284 in her room sitting in her wheelchair watching television. The wheelchair was positioned between the bed and the entrance door to the room. Resident #284's left arm was restricted by a sling and she indicated by pointing to the sling that she could not move her arm. The call light was attached to the bed linens about 12 inches from her Left arm and out of reach from her right arm. Resident #284 was awake and alert. Bilateral foot rests were in place and there was a floor mat in place on the opposite side of bed. She wore non-skid shoes. Observation on 6/23/22 at 10:03 AM revealed Resident #284 in her room in bed. The bed was in the lowest position with floor mat in place. The call light was attached to the bed linens above her head on the left side of the bed. Her left arm was in a sling and she reported she could not move her arm. The call light was out of reach of her left and right hands. Record review revealed Resident #284 was admitted to the facility on [DATE] with multiple diagnoses including Displaced fracture of shaft of humerus, left arm 5/31/22, history of falls, Hypertension, Psychosis, Depression, Anxiety, Alzheimer's, Dementia with Behavioral Disturbances, Osteoarthritis, and Cataracts. Review of the minimum data set (MDS) dated [DATE] revealed Resident #284 had a BIMS (brief interview for mental status) score of 4 indicating severely impaired cognition. Mood indicators included feeling down/depressed, trouble sleeping and either moving slowly or restlessness. Resident #284 needed extensive ADL (activities of daily living) assistance, was vocationally incontinent, had one fall with injury, and medications included the use of antipsychotic, antianxiety, and antidepressants. Review of the care plan revealed Resident #284 has alteration in musculoskeletal status as evidenced by displaced spiral fracture of shift of humerus, left arm and is at risk for falls secondary to decreased activity tolerance, fall scale 65, use of cardiovascular and psychotropic medications and incontinence. 4/11/22 incident reported 5/21/22 Incident reported 5/28/22 Resident was observed walking by herself, suddenly she lost her balance and fell to the floor over the left side of her body. The staff tried to assist but unable to reach her on time. Resident verbalized she was trying to go to the bathroom without a call for assistance. Resident refer pain 3 on scale of 10 to left arm. Deformity to left arm. Resident readmitted from hospital on 6/8/22. Approaches included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 4 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 -Be sure residents' call light is in reach and encourage resident to use it for assistance as needed. Level of Harm - Minimal harm or potential for actual harm -Bed to lowest position -Bilateral floor mats at all times Residents Affected - Few -Appropriate footwear -Frequent visualization - check every 1 hour -Toilet after meals and bedtime -Red star on ID (identification) band, fall identification Interview with a Certified Nursing Assistant (C N A), staff L on 6/24/22 at 11:44 AM revealed Resident # 284 is at risk for falls. I know she needs to have floor mattresses on both sides of the bed. The bed has to be low. The call light needs to be next to her. The call light has to be in the right hand because she has a fracture on the left side. Resident # 284 is physically able to use the call light. We have to make sure she has the light to call for help and to use the bathroom. Resident # 284 is alert, but confused sometimes. She is able to tell me her basic needs, like when she needs to use the bathroom. I have to make sure the call light is near her right hand because she has a sling on her left arm. Interview with a Registered Nurse (RN), staff N on 6/24/22 12:21 PM revealed Resident # 284 is at risk for falls so she is closely monitored. She has a low bed and mats and we have to make sure her call light is in reach. She has not been trying to get up so often recently since she fractured her humerus but she has been identified at risk due to attempts to get up without help and risk for falls. Based on observation, record review and interview, the facility failed to ensure a resident's comprehensive care plan was followed related to the 1) Use of hand rolls for a resident with bilateral contractures of the upper extremities for one (Resident #131) out of two residents reviewed for position and mobility out of nineteen residents with contractures and 2) Failed to follow the fall risk care plan for one (Resident #284) out of 38 sampled residents as evidenced by failure to ensure the call light was in reach. There were a total of 299 residents residing in the facility at the time of this survey. The findings included: 1) Record review of the Resident Mobility and Range of Motion Policy and Procedure (Revised January 2022) documented: Policy Statement-1) Residents will not experience an avoidable reduction in range of motion (ROM); 2) Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM and 3) Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility. Policy Interpretation and Implementation-1) As part of the resident's comprehensive assessment, the nurse will identify the resident's: a) current range of motion of his or her joints; 2) As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications relate to ROM and mobility, including: e) contractures and 4) Interventions may include the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 5 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 provision of necessary equipment. Level of Harm - Minimal harm or potential for actual harm An initial observation of Resident #131 was conducted on 06/20/22 at 9:30 AM. The resident was sitting up in bed with the television on, bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Residents Affected - Few Second observation of Resident #131 was conducted on 06/21/22 at 8:21 AM. The resident was sitting up in bed, asleep with bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Third observation of Resident #131 was conducted on 06/22/22 at 7:26 AM. The resident was sitting up in bed, asleep with bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Record review of the Demographic Face Sheet for Resident #131 documented the resident was admitted on [DATE] with a diagnosis of hemiplegia, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, alzheimer's disease, dementia and contracture left hand. Review of the Physician's Order Sheet (POS) for June 2022 for Resident #131 documented the resident was issued bilateral hand rolls to be worn daily/daytime in an attempt to maintain bilateral hand palmar area skin integrity every day. The order was written on 6/16/2022. Review of Resident #131's Joint Limitations care plan dated 6/16/22 documented the resident was at risk to decrease mobility and muscle strength with hand contractures; Goal: Risk of limitations will be minimized on daily basis by next review date; Interventions: Bilateral hand rolls protector at all times except for hygiene/grooming and ROM (range of motion) for contracture management. Fourth observation of Resident #131 was conducted on 06/23/22 at 12:21 PM. The resident was sitting up in bed with television on, bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Interview and observation with Staff O, Nurse RN (Registered Nurse) was conducted on 6/23/22 at 12:22 PM. She stated, I have only worked with the resident two times. I don't know if she is supposed to have hand rolls. Observation with the nurse revealed the resident had bilateral hand contractures and did not have bilateral hand rolls. Interview and observation with Staff P, CNA (Certified Nursing Assistant) was conducted on 6/23/22 at 12:24 PM via Spanish translator. She revealed the resident's hand rolls went to the laundry because they are dirty and that is why she doesn't have them on. She bathes her in the morning, takes them off, then put them back on after the bath. She revealed the resident should have the bilateral hand rolls on. Interview with Staff Q, Nurse RN on 6/24/22 at 11:16 AM. She stated, The doctors order say the resident is to have bilateral hand rolls daily. Interview with Staff R, OT (Occupational Therapist) on 6/24/22 at 2:28 PM. She stated, She has splints and hand rolls to prevent further joint contractures. She does have an order for splints and hand rolls. Patient will tolerate bilateral hand rolls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 6 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 Interview with Staff S, RN Restorative Nursing on 6/24/22 at 3:09 PM. He stated, She has an order and is care planned for bilateral hand rolls, every time except when having personal care done. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 7 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that bilateral handrolls were worn to prevent worsening bilateral hand contractures for one (Resident #131) out of two residents reviewed for position and mobility out of nineteen residents with contractures. There were a total of 299 residents residing in the facility at the time of this survey. The findings included: Record review of the Resident Mobility and Range of Motion Policy and Procedure (Revised January 2022) documented: Policy Statement-1) Residents will not experience an avoidable reduction in range of motion (ROM); 2) Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM and 3) Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility. Policy Interpretation and Implementation-1) As part of the resident's comprehensive assessment, the nurse will identify the resident's: a) current range of motion of his or her joints; 2) As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications relate to ROM and mobility, including: e) contractures and 4) Interventions may include the provision of necessary equipment. Review of the Use of Assistive Devices and Equipment Policy and Procedure (Revised January 2022) documented: Policy Statement-Our facility maintains and supervises the use of assistive devices and equipment for residents. Policy Interpretation and Implementation-1) Certain devices and equipment will assist with resident mobility, safety and independence are provided for residents and 4) The facility provides the residents with assistive devices to maintain ROM and minimize the risk for further contractures based on the evaluation of the rehabilitation department. These devices may include splints, handrolls, braces and other adaptive equipment. Devices are indicated in the plan of care with directions on when to apply and remove. An initial observation of Resident #131 was conducted on 06/20/22 at 9:30 AM. The resident was sitting up in bed with the television on, bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Second observation of Resident #131 was conducted on 06/21/22 at 8:21 AM. The resident was sitting up in bed, asleep with bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Third observation of Resident #131 was conducted on 06/22/22 at 7:26 AM. The resident was sitting up in bed, asleep with bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Review of the Demographic Face Sheet for Resident #131 documented the resident was admitted on [DATE] with a diagnosis of hemiplegia, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, alzheimer's disease, dementia and contracture left hand. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #131 dated 4/21/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 03 out of 15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 8 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating cognitive impairment and the resident was not able to make her needs known. The resident required total dependence assistance with one-two+ persons physical assist for ADLs (Activities of Daily Living) and had upper extremity impairment on both sides. Review of the Physician's Order Sheet (POS) for June 2022 for Resident #131 documented the resident was issued bilateral hand rolls to be worn daily/daytime in an attempt to maintain bilateral hand palmar area skin integrity every day. The order was written on 6/16/2022. Review of Resident #131's Joint Limitations care plan dated 6/16/22 documented the resident was at risk to decrease mobility and muscle strength with hand contractures; Goal: Risk of limitations will be minimized on daily basis by next review date; Interventions: Bilateral hand rolls protector at all times except for hygiene/grooming and ROM (range of motion) for contracture management. Review of the Occupational Therapy (OT) Plan of Care for Resident #131 dated 6/15/22 documented the patient will tolerate bilateral hand rolls in an attempt to maintain palmar area skin integrity as well as to prevent further joint flexion contracture development. Fourth observation of Resident #131 was conducted on 06/23/22 at 12:21 PM. The resident was sitting up in bed with television on, bilateral one quarter side rails and had bilateral hand contractures. No hand rolls were observed in the resident's hands. Interview and observation with Staff O, Nurse RN (Registered Nurse) was conducted on 6/23/22 at 12:22 PM. She stated, I have only worked with the resident two times. I don't know if she is supposed to have hand rolls. Observation with the nurse revealed the resident had bilateral hand contractures and did not have bilateral hand rolls. Interview and observation with Staff P, CNA (Certified Nursing Assistant) was conducted on 6/23/22 at 12:24 PM via Spanish translator. She revealed the resident's hand rolls went to the laundry because they are dirty and that is why she doesn't have them on. She bathes her in the morning, takes them off, then put them back on after the bath. She revealed the resident should have had the bilateral hand rolls on. Interview with Staff Q, Nurse RN on 6/24/22 at 11:16 AM. She stated, The doctors order say the resident is to have bilateral hand rolls daily. Interview with Staff R, OT (Occupational Therapist) on 6/24/22 at 2:28 PM. She stated, She has splints and hand rolls to prevent further joint contractures. She does have an order for splints and hand rolls. Patient will tolerate bilateral hand rolls. Interview with Staff S, RN Restorative Nursing on 6/24/22 at 3:09 PM. He stated, She has an order and is care planned for bilateral hand rolls, every time except when having personal care done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 9 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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, record review and interview, facility failed to adequately supervise and failed to ensure the call light was consistently in reach for one (Resident #284) of three residents reviewed for falls as evidenced by multiple observations of Resident #284 with her call light out of reach after sustaining multiple falls with one resulting in a fracture. There were 299 residents residing in the facility at the time of the survey. The findings included: Observation on 6/21/22 at 1:04 PM revealed Resident #284 in her room in bed. Resident #284's left arm was in a sling restricted use of the arm. The call light was attached to the bed linens on her left side. The bed was in a low position and there was a mat on the floor to her left side. Observation on 6/22/22 at 10:20 AM revealed Resident #284 in her room sitting in her wheelchair watching television. The wheelchair was positioned between the bed and the entrance door to the room. Resident #284's left arm was restricted by a sling and she indicated by pointing to the sling that she could not move her arm. The call light was attached to the bed linens about 12 inches from her Left arm and out of reach from her right arm. Resident #284 was awake and alert. Bilateral foot rests were in place and there was a floor mat in place on the opposite side of bed. She wore non-skid shoes. Observation on 6/23/22 at 10:03 AM revealed Resident #284 in her room in bed. The bed was in the lowest position with floor mat in place. The call light was attached to the bed linens above her head on the left side of the bed. Her left arm was in a sling and she reported she could not move her arm. The call light was out of reach of her left and right hands. Record review revealed Resident #284 was admitted to the facility on [DATE] with multiple diagnoses including Displaced fracture of shaft of humerus, left arm 5/31/22, history of falls Hypertension, Psychosis, Depression, Anxiety, Alzheimer's, Dementia with Behavioral Disturbances, Osteoarthritis, and Cataracts. Review of the minimum data set (MDS) dated [DATE] revealed Resident #284 had a BIMS (brief interview for mental status) score of 4 indicating severely impaired cognition. Mood indicators included feeling down/depressed, trouble sleeping and either moving slowly or restlessness. Resident #284 needed extensive ADL (activities of daily living) assistance, was vocationally incontinent, had one fall with injury, and medications included the use of antipsychotic, antianxiety, and antidepressants. Review of the care plan revealed Resident #284 has alteration in musculoskeletal status as evidenced by displaced spiral fracture of shift of humerus, left arm and is at risk for falls secondary to decreased activity tolerance, fall scale 65, use of cardiovascular and psychotropic medications and incontinence. 4/11/22 incident reported 5/21/22 Incident reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 10 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 5/28/22 Resident was observed walking by herself, suddenly she lost her balance an fell to the floor over the left side of her body. The staff tried to assist but unable to reach her on time. Resident verbalized she was trying to go to the bathroom without a call for assistance. Resident refer pain 3 on scale of 10 to left arm. Deformity to left arm. Residents Affected - Few Resident readmitted from hospital on 6/8/22. Approaches included: -Be sure residents' call light is in reach and encourage resident to use it for assistance as needed. -Bed to lowest position -Bilateral floor mats at all times -Appropriate footwear -Frequent visualization - check every 1 hour -Toilet after meals and bedtime -Red star on ID (identification) band, fall identification Review of the physician orders revealed Resident #284 had orders for bed in lowest setting at all times for fall precaution, frequent visualization, check for needs every 2 hour for fall precaution, red star placed on ID wrist band, status post alleged fall identification and increased supervision, all precautions every shift, and keep left arm immobilizer/left sling on at all times every shift for left humerus mid-shaft spiral fracture. Record review revealed Resident #284 has sustained multiple falls in the past 120 days based on the following review of post fall assessments and nursing progress notes: 4/12/22 Post fall assessment. On 4/11/22 Resident observed on sitting position in from of the bed, urine observed on the floor. As resident verbalized she was trying to go to the bathroom without calling for assist, lost balance and slid to the floor. Pain 3 of 10. Prn (as needed) pain medication administered, effective. No skin lesions. X-ray negative for fracture or dislocation. Assessment complete, no new redness or bruises. Able to move upper and lower extremities by herself without pain. ARNP (Advanced Registered Nurse Practitioner) notified, new order for x-ray of lumbar spine, bilateral hips, and rib cage. Resident reeducated to call for assist. Care plan updated, new interventions added. Call light in reach, bed in low setting. Progress notes: 4/11/22 Upon entering the room, C N A (Certified Nursing Assistant) noted resident sitting on floor in front of bed. Noted floor to be wet. Per resident I fell on the floor:. Complained of right lateral side pain near breast. Able to move extremities. Assist back to bed. Message left for PA (Physicians Assistant). Message left with son. PA called back with orders for x-rays. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 11 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 4/12/22 X-rays done Level of Harm - Minimal harm or potential for actual harm 413/22 X-ray results, no acute traumatic bony findings. MD (Medical Doctor) aware. Residents Affected - Few 5/21/22 Post fall assessment. Resident was observed in kneeling position on the floor. As resident verbalized, she was trying to go to the bathroom without call for assistance, lost her balance and slid to the floor. Pain to right elbow and bilateral knees. No skin lesions. 5/28/22 Post fall assessment. Resident observed in kneeling position on floor, verbalized she was trying to go to the bathroom without call for assist and lost balance. No skin lesions. Pain to right elbow and bilateral knees. Resident did not call for assist. 5/30/22 Post fall assessment. Resident observed walking in the hallway by herself, suddenly lost her balance and fell to the floor over the left side of her body. The staff tried to assist, unable to reach resident in time. Pain 3 of 10. Deformity to left arm. Doctor notified, order for transfer to hospital. Progress Notes: 5/28/22 During rounds, resident observed coming out of her room walking in the hallway. I was unable to reach her and she fell. Alert, oriented x 1, when asked she said she was trying to go to the bathroom by herself. Observed lying on the floor on left side complaining of pain to left arm. Head to toe assessment performed, able to move lower extremities, but verbalized pain to left arm, bone deformity observed. Tylenol administered. Call placed to doctor, order for transfer. Call placed to son. 5/31/22 Return from hospital with displaced spiral fracture of shift of humerus, left arm. Pain management ordered. Review of fall risk assessment conducted on admission, readmissions, quarterly and post falls indicated Resident # 284 was identified at high risk for falls. Interview with the Compliance Officer/Risk Manager and the Assistant Director of Nursing (ADON), staff F on 6/23/22 at 12:38 PM revealed the Fall Risk Assessments are done on admission, readmission, significant changes, quarterly and post falls. Resident # 284 was identified at high risk for falls. She has a history of Syncope upon admission. She also has behaviors. She had had several falls recently. On 4/11/22 upon entering the room the C N A noticed the resident on the floor in front of the bed and the floor was wet. Resident reported she was going to the bathroom without assist. She voided on floor and fall in front of bed and slipped on urine. The investigation included interviews with the nurse and C N A. At this time Resident # 284 was able to walk and she forgets to call for assistance. This episode she was walking to the bathroom, but she did not make it in time. Thirty minutes prior to fall the C N A had passed by the room and she was asleep in a low bed with the call light in reach. The x-rays were negative for fracture. We have a weekly fall prevention meeting to review all falls and assess need for new interventions. Intervention after this fall was for increased monitoring, check every 1 hour. On 5/21/22 Resident # 284 went to the bathroom without assist. She was found on the bathroom floor on her knees. she was assessed with no neurological abnormalities. This occurred at 5:30 PM. She complained of pain to her right knew and elbow. X-rays were negative for fracture or dislocations. The x-rays showed diffuse osteopenia noted. The investigation revealed Resident #284 stood by herself without calling for assist. The care plan was updated and interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 12 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 included instruction to staff to offer toilet assist after all meals and at bedtime. On 5/28/22 Resident # 284 was observed coming out of the room walking in hall at 8:54 PM. The Nurse tried to reach her but was unable to stop the fall. She was transferred to the hospital. She was readmitted with a fracture to the left arm. The investigation included interview with the C N A which revealed she had taken the resident to the bathroom and providing care at 8:45 PM. She assisted her back to bed and told her to use the call light for assist. The C N A was in another room caring for a resident when she heard the nurse say the resident fell. Interview with a Certified Nursing Assistant (C N A), staff L on 6/24/22 at 11:44 AM revealed Resident # 284 is at risk for falls. I know she needs to have floor mattresses on both sides of the bed. The bed has to be low. The call light needs to be next to her. The call light has to be in the right hand because she has a fracture on the left side. Resident # 284 is physically able to use the call light. We have to make sure she has the light to call for help and to use the bathroom. Resident # 284 is alert, but confused sometimes. She is able to tell me her basic needs, like when she needs to use the bathroom. I have to make sure the call light is near her right hand because she has a sling on her left arm. Interview with a Registered Nurse (RN), staff N on 6/24/22 12:21 PM revealed Resident # 284 is at risk for falls so she is closely monitored. She has a low bed and mats and we have to make sure her call light is in reach. She has not been trying to get up so often recently since she fractured her humerus but she has been identified at risk due to attempts to get up without help and risk for falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 13 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 provide respiratory care consistent with professional standards of care, as evidenced by 2 out of 38 sampled residents (Residents' #24 and #296) oxygen (02) concentrators' settings not being at the prescribed rate during several observations. This had the potential to affect 49 residents in the facility receiving respiratory care at the time of this survey. Residents Affected - Few The Findings Included: During Observation on 6/20/22 at 09:04 AM Resident #296 in bed, bed in lowest position, air mattress, Geri chair, talking to herself, bilateral heel protectors, Tube Feeding (TF) Isosource running at 70 milliliters per hour (ml/hr.) dated 6/20/22, 02 running at 3.5 liters per minute (LPM), (photo available) via Nasal Cannula, (NC) not attached to resident's nares (Nostrils), NC tubing on bed. During Observation on 06/21/22 at 09:34 AM Resident #296 was in bed asleep 02 at 3.5 LPM, NC on head not attached to nares, bed in low position, TF running at 70 ml/hr. isosource, dated 6/21/22. During observation on 06/22/22 at 10:10 AM PM Resident #296 in bed awake, bed in lowest position, NC on face not in nares, 02 running at 3LPM, TF running at 70ml/hr., no distress noted. During Observation on 06/23/23 at 12 11PM Resident #24 in bed awake, 02 running at 4 LPM, NC attached correctly. During Observation on 06/20/22 at 09:22 AM Resident #24 in bed, high back wheel chair in room, 02 via NC at 1.5 LPM, (photo available). During observation on 06/21/22 at 09:37 AM Resident #24 in bed, coughing, 02 running at 1.5LPM via NC. During Observation on 06/23/22 at 12:05 PM Resident #24 in bed awake, 02 running at 2 LPM via NC, no distress noted. Review of the medical records for Resident #296 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Acute Chronic Respiratory Failure with Hypoxia and Personal History of Pneumonia (Recurrent). Review of the medical records for Resident #24 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure. Review of the Physician's Orders Sheet for June 2022 revealed Resident #296 had orders that included but were not limited to: Oxygen Via Nasal Cannula at 4 L/min continuous every shift for Respiratory Failure. Review of the Physician's Orders Sheet for June 2022 revealed Resident #24 had orders that included but were not limited to: Oxygen at 2LPM via Nasal Cannula as needed for shortness of breath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 14 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 Record review of Resident # 296's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief Interview for Mental Status Score (BIMS) 3 indicating resident has severely impaired cognition. Section G-Total Dependence of Activities of Daily Living. Section J-Shortness of breath when lying flat, shortness of breath or trouble breathing with exertion and Section O-Oxygen therapy received in the last 14 days. Residents Affected - Few Record review of Resident # 24's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief Interview for Mental Status Score -7, indicating resident has severely impaired cognition. Section Gextensive assistance for Activities of Daily Living. Section J-No shortness of breath and Section O-Received oxygen therapy in the last 14 days. Record review of Resident #296 's Care Plans Reference Date 5/26/22 revealed: Resident has oxygen therapy via nasal cannula @ 4LPM continuous for Respiratory failure. Goal: Resident will display optimal breathing patterns daily through review date. Interventions: Give medications as ordered by physician, observe/document side effects and effectiveness, monitor oxygen saturation as ordered, observe skin color for development of cyanosis, oxygen via nasal cannula @ 4LPM continuous, promote lung expansion and improve air exchange by positioning with proper body alignment and if tolerated, head of bed elevated. Record review of Resident #24 's Care Plans Reference Date 6/17/22 revealed: Resident has oxygen therapy via nasal cannula @ 2LPM continuously for Short of Breath (SOB) related to Congestive Heart Failure (CHF), COPD, and Chronic Respiratory failure. Goal: Resident will display optimal breathing patterns daily through review date. Interventions: Give medications as ordered by physician. Observe/document side effects and effectiveness, monitor oxygen saturation as ordered, observe skin color for development of cyanosis, oxygen via nasal cannula @ 2LPMcontinuously, promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, head of bed elevated. Interview on 06/22/22 at 10:00 AM with Registered Nurse, Unit 7 floor Supervisor (Staff D) walked with surveyor to room [ROOM NUMBER], observed resident #24 oxygen (02) at 1.5LPM via 02 concentrator, (Staff D) stated sometimes when the concentrator gets bumped or moved around it will go up and down. (Staff D) stated, I will check the orders and change to the right settings. Interview on 06/22/22 at 10:05 AM with Staff D, walked with surveyor to room [ROOM NUMBER]. resident #296 observed lying in bed, nasal canula on her face not in her nose, 02 running at 3LPM via 02 concentrator, staff D stated I will check the orders and change to right settings, and I will do an in-service with the nurses right now. Interview on 06/23/22 at 09:23 AM with Assistant Director of Nursing (Staff F) stated every day when the nurses arrive at the beginning of their shift during rounds, they have to check the resident's oxygen levels, to see if the orders are correct, check to make sure the resident is using the nasal canula properly, if the resident is not using the NC correctly, we check the saturation immediately, check the orders on the Electronic Medication Administration Record (EMAR) to make sure they are correct, we talk with the Doctor, if the resident is able to be without the oxygen for periods of time, we get the orders updated to PRN. Interview on 06/23/22 at 10:38 AM Registered Nurse, unit 7 south unit (Staff E) when asked about how and when they check on their residents, specifically the residents on oxygen, Staff E stated, we received information from the other nurses about our residents during shift report, I check on my residents during rounds, during medication administration and several times during the day. If the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 15 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 resident is on oxygen and is not wearing their nasal canula properly, I make sure it is placed correctly on the resident and I check the concentrators and compare the orders in the EMAR to the setting to make sure the oxygen is correct. Review of the facility policy and procedures titled, Respiratory Care revision date 01/2022 states: Oxygen Method of delivery (liters, room air) (make sure the flow rate matches the order) Precautions (e.g., proper handling of oxygen concentrators), Oxygen in use signs present wherever oxygen is administered, Nasal cannulas are to be changed every Sunday. Placed in bag and dated. Event ID: Facility ID: 106031 If continuation sheet Page 16 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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** 2. During the Medication Administration Observation on 06/22/2022 at 8:00AM with Staff J, Registered Nurse on the 2nd floor, Marlins cart. Staff J was observed to crush Metoprolol ER (Extended Release) (a beta-blocker that affects the heart and circulation, blood flow through arteries and veins) 50 mg, 1 tablet; Vitamin C 500mg, 1 tablet; Folic Acid 1 mg, 1 tab. Metformin 500 mg, 1 tablet, and Sertraline 50 mg, 1 tablet. Staff J was asked whether the medications could be crushed and she replied the medications could be crushed. The crushed medications were given in apple sauce to the resident. During the Medication Administration Observation on 06/22/2022 at 8:30AM with Staff K, a Licensed Practical Nurse. While administering medications to Resident #21 the following medications were prepared for administration, Calcium D3 600-400 1 tablet, Docusate Sodium 100mg, 1 capsule, Duloxetine 60 capsule, 1 tablet, Glucosamine Chond 500-400mg capsule, Potassim Chloride ER 20 MEQ (milliequivalents) 1 capsule, Daily Vite 1 tab, Metoprolol Tartrate 25 mg 1 tablet. While the resident was taking the medications orally the resident requested the medications be broken. Staff K was observed to break the large tablets with her bare hands and did not put on gloves. On 06/22/22 at 03:11 PM, the facility's Pharmacy Consultant was asked whether the Metoprolol ER 50 MG could be crushed. The Pharmacy Consultant looked at the medication order and reported the medication shouldn't be crushed, but they would get the medication changed to the sprinkles. Review of the facility's policy and procedures titled, Administering Medications revised 01/2022 states: 3. Medications must be administered in accordance with the orders, including any required time frame. 14. Staff shall follow established infection control procedures (e.g .gloves ) when these apply to the administration of medications. Based on Observation, Record Review and Interview, the facility failed to provide Pharmaceutical Services to meet the needs of 6 out of 38 sampled residents (Residents #21, #130, #192, #242, #295, and #360). This had the potential to affect 299 residents in the facility receiving care at the time of this survey. The Findings Included: 1. During the Medication Administration observation on the seventh floor on 6/21/22 at 8:45AM with Registered Nurse (Staff B), Staff B crushed the medication (Ferrous Sulfate 1 Tablet 325 MG) (milligrams) before administering the medication to Resident #130. During Medication Administration observation on the seventh floor on 6/21/22 at 9:06AM with Registered Nurse (Staff A), Staff A was observed throwing an oblong shaped white pill that fell on the floor, in the garbage attached to the medication cart. During Narcotic Count Review on the fifth floor, Medication cart two on 06/21/22 at 11:13 AM with Registered Nurse (Staff C) Resident #295's Lorazepam 0.5 Milligram (mg), (1) tablet count in the narcotic book was 5 and last given on 6/20/22 at 17:00, the bingo card count was - 4. The Electronic Medication Administration Record (EMAR) revealed the medication was given on 6/21/22 at 8:28 AM. Resident #242's Clonazepam 0.5 mg (1) tablet count in the narcotic book was-53, and last given on 6/20/22 at 20:54/8:54PM, the bingo card count was-52. The EMAR revealed the medication was given on 6/21/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 17 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 at 8:31AM. Resident #192's Alprazolam 0.25mg (1) tablet count in the narcotic book was-25, and last given on 6/20/22 at 17:00, the bingo card count was-24. The EMAR revealed the medication was given on 6/21/22 at 8:56AM. Review of the medical records for Resident #130 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Respiratory Failure and Anemia. Review of the medical records for Resident #295 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Generalized Anxiety. Review of the the medical records for Resident # 242 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Generalized Anxiety Disorder. Review of the medical records for Resident #192 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Anxiety Disorder. Review of the Physician's Orders Sheet for June 2022 revealed Resident #130 had orders that included but were not limited to: 3/25/22 to 6/24/22-Ferrous Sulfate Tablet 325 MG-Give 1 tablet via peg 2 times a day for Anemia. Start Date 6/24/22-Ferrous Sulfate Elixir 220 (44Fe) MG/5ML- Give 7.5ML via peg (Percutaneous Endoscopic Gastrostomy) two times a day for Anemia. Review of the Physician's Orders Sheet for June 2022 revealed Resident #295 had orders that included but were not limited to: Lorazepam tablet 0.5 Milligram (MG)-Give 1 tablet by mouth two times a day related to Generalized Anxiety. Review of the Physician's Orders Sheet for June 2022 revealed Resident #242 had orders that included but were not limited to: Clonazepam Tablet 0.5 Milligram (MG)-Give one tablet by mouth two times a day related to Generalized Anxiety Disorder. Review of the Physician's Orders Sheet for June 2022 revealed Resident #192 had orders that included but were not limited to: Alprazolam 0.25 Milligram (MG)-Give 0.125MG orally two times a day related to anxiety disorder, administer one half tablet 0.125mg. Record review of Resident #130 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief Interview for Mental Status Score-Unable to determine. Record review of Resident #295 's quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief Interview for Mental Status score (BIMS) -13 indicating resident is cognitively intact. Record review of Resident #242 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section CBrief Interview for Mental Status score (BIMS)-unable to determine. Record review of Resident #192 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-Brief Interview for Mental Status score (BIMS)-9 indicating resident has moderate cognitive impairment Interview on 6/21/22 at 9:28AM with Staff A, Unit 7 cart #2's nurse stated, I'm supposed to dispose medication in the toilet, I was nervous and had many things in my hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 18 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 On 06/21/22 at 09:58 AM Assistant Director of Nursing (ADON) (Staff G), and the DON brought in-services conducted with Staff A about medication disposal, and notified the surveyor the medication was taken out of the garbage and flushed down the toilet. Surveyor informed the DON and ADONS at that time of other issues identified during medication administration. Interview on 6/21/2022 at 11:30AM with Staff C, Staff C stated, I know I am supposed to sign out narcotic medications right away after I take it from the cart, today is just a crazy day, many things going on. On 6/23/22 at 3:40PM, interview with the Facility's Pharmacy Consultant, when asked if the medication Ferrous Sulfate can be crushed for administering to residents he stated, No. Interview on 06/24/22 at 1:02 PM with the Unit 7 floor Supervisor Registered Nurse (Staff D) stated, Resident #130's Ferrous Sulfate 325 MG medication 1 tablet cannot be crushed, I confirmed this with the facility's pharmacy, we changed the order to liquid ferrous sulfate, in-serviced all the nurses and Dietitians and we will be speaking with the Doctors about this medication. Review of the facility's policy and procedures titled, Administering Medications revised 01/2022 states: Medications must be administered in accordance with the orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the persons preparing or administering the medication shall contact the resident's attending Physician or the facility's Medical Director to discuss the concerns. Review of the facility policy and procedures titled, Discarding and Destroying Medications revised 01/2022 states: Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. Review of the facility policy and procedures titled Controlled Substances, revised 01/2022 Policy Interpretation and Implementation #8 states: Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 19 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review, the facility failed to store food under sanitary condition by ensuring food items stored in the nourishment room refrigerators were dated and labeled. There were a total of 299 residents residing in the facility at the time of this survey. The findings included: Observation of the 3rd Floor Nourishment Room on 6/20/22 at 11:40 AM. The refrigerator contained resident's food and employee lunches. Three lunch bags were identified as belonging to employees. The resident's foods were labeled with the resident's name and dates on them. The lunch bags were not labeled nor dated. Photographic evidence submitted. Observation and interview with Staff K, Licensed Practical Nurse (LPN) on 6/20/22 at 11:41 AM revealed the refrigerator in the 3rd floor nourishment room contained employee lunch bags along with the resident's foods. She revealed that yes, sometimes the employee would store their lunch bags in the nourishment room refrigerator. Observation of the 7th Floor Nourishment Room on 6/20/22 at 11:44 AM. The refrigerator contained resident's food and employee lunches. Two lunch bags were identified as belonging to employees. The resident's foods were labeled with the resident's name and dates on them. The lunch bags were not labeled nor dated. Observation and interview with Staff Q on 6/22/22 at 10:30 AM of the 3rd floor nourishment room revealed the refrigerator was empty. She stated, The employees don't store their lunches in this refrigerator. The employees have a staff lounge on the 2nd floor with a refrigerator to store their lunches and lunch bags. Interview with Staff T, RD (Registered Dietitian) on 6/22/22 at 11:06 AM. She stated, The refrigerator downstairs on the 2nd floor is supposed to be used by the employees to store their lunches. The floor pantries are for the patients food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 20 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F755 Pharmacy Services/Procedures/Pharmacist/Records as evidenced by the facility failed to provide pharmaceutical services to meet the resident's needs for Resident # 21, 130, 192, 242, 295, & 360. This practice has the potential to increase the risk of negative resident outcomes and to affect all 299 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification and complaint investigation survey with an exit dated January 16, 2020, Pharmacy Services/Procedures/Pharmacist/Records was cited related to the facility failed to reconcile a controlled medication for one medication cart (the 7th floor medication cart) out of twelve medications carts in the facility during this survey. Interview with Staff F Assistant Director of Nursing (ADON) and Compliance Officer on 06/24/22 at 03:18 PM. Staff F stated the Quality Assurance/Quality Assurance Performance Improvement (QA/QAPI) meetings takes place the first Wednesday of every month, and quarterly meetings. Staff F (ADON) stated in the last three months we interviewed residents to see if they had concerns, we did environmental rounds to observe the facility's environment. We, also, oversaw the nursing staff, about medications, we did quality assurance interviews for nurses. We had meeting with the departments head, for them to interview the staff and do rounds in the floor, to identify issues through observations and discussions with the staff. We identified concerns with residents falls, we met with therapy department, also checked on medications. We had a weekly Fall Prevention meeting, to see what we can do to minimize the risk of fall. Staff F stated she reviewed the documentation, oxygen, catheters, physician orders, if the interventions were in place, resident's behaviors, medication pass, checked medication rooms. We had new hired nurses, and we had in-services education training for new nurses, to make sure they were doing the correct work. The Certified Nursing Assistant (CNAs) were receiving in-service education training for fall prevention. New hired wound care nurses were receiving in-service education training as well, to make sure they were doing the wound care right and following infection prevention standards. The CNAs were receiving in-services education training on how the resident's devices should be put on the residents. The staff was trained on how to use the proper Personal Protective Equipment (PPE) when residents were isolated. We had in-service education on how the medication should be disposal. We had in-services education for all nursing staff for change of resident's condition, call light within resident's reach and time to answer it, checked temperatures of the refrigerators. We were reminded the staff that refrigerators in the nourishment rooms were only for resident's food. We also checked dialysis residents, to follow physician orders and the fluids restriction. We checked restorative department, bladder and bowel training not to lose the function. Weigh loss were also revised. Staff F stated for Narcotics Medication not signed: the facility will provide in-services education for all nurses and random observation to prevent it happened again. Medication Disposal: In-services education to all nurses and random observation when the nurses were passing medication. Medication error: In-services education for all nurses, random observations by quality assurance officer. Facility's policies and procedures for medication will be reviewed, the pharmacist will be asked for assistance. Oxygen: We had nurses in charge to made sure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 21 of 22 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 106031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Nursing & Rehabilitation Center, Inc. 955 NW 3rd St Miami, FL 33128 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 FORM CMS-2567 (02/99) Previous Versions Obsolete physician orders were followed and educate the nurse on the importance of following the physician orders. Nourishment Pantry: We checked the refrigerators and the freezer temperatures every morning. We checked if any staff lunch bags were in the resident's refrigerators. We checked the date in the food labels, if it had a date more than three days, it was thrown away. Facility's policies and procedures will be revised and in-service education to all staff. Range of Motion devices (hand rolls): educated the nursing staff to follow physician orders for hand rolls, the Certified Nursing Assistant oversaw placing devices to residents. Visitation Policies not uploaded in facility website: this deficiency was corrected, it was uploaded, the revision was made was uploaded in the facility website. Call lights not in easy reach to residents: In-service education to all staff to place the call light within reach or within reach of resident's dominant side. Supervision: In-service education to all staff, to do rounds to make sure residents needed assistance. Restraints (hands) Review policies and procedures, review physician orders, if any. Review the medical records to see if the resident needed the restraint. Random observations and in-service education to nursing staff. Event ID: Facility ID: 106031 If continuation sheet Page 22 of 22