Inspection·July 20, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy and procedures on Certifying Accuracy of the Resident Assessment revised January 2023 revealed: Policy Statement - Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Residents Affected - Few Policy Interpretation and Implementation 2.-Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 2 of 12 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 07/20/2023 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** Based on observation, record review and interview, the facility failed to ensure pharmaceutical procedures were followed during medication administration for two (2) (Resident #233 and #92) out of seven (7) residents observed for medication administration with 35 opportunities and one (1) medication cart electronic screen was not locked on the 5th floor medication cart #2. There were 303 residents residing in the facility at the time of this survey. The Findings Included: 0n 07/18/23 at 8:40 AM during the medication administration observation with Registered Nurse (Staff B). Staff B did not have on the medication cart and was unable to administer one prescribed medication (Apixaban Oral Tablet 5 Milligram (mg) 1 tablet) for Resident # 233. Review of Resident # 233 's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Personal history of other venous thrombosis and embolism, long term (current) use of anticoagulants and Unspecified atrial fibrillation. Review of Resident #233's physician orders for July 2023 revealed, on 7/18/23-7/18/23 Eliquis Oral Tablet 5 MG (Apixaban)-Give 1 tablet by mouth one time only related to personal history of other venous thrombosis and embolism. On 7/18/23-Apixaban Oral Tablet 5 Milligram (mg) (Apixaban) Give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. On 7/18/23 at 9:03AM, Registered Nurse, Staff B stated the last time Apixaban 5 MG was ordered for Resident #233 was 6/17/23, Staff B resent the order for Apixaban 5 mg via the computer today on 7/18/23. The surveyor asked Staff B, when do you usually reorder medications for the residents. Staff B stated, via a Spanish/English translation by the Assistant Director of Nursing (ADON), when the medication is on the last line on the bingo card, we reorder the medication. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented, a Brief Interview for Mental Status (BIMS) score 13 on a 0-15 scale, indicating the resident is cognitively intact. On 07/18/23 at 9:15 AM, the surveyor observed the computer screen on the 5th floor, medication cart #2 was unlocked, displaying the residents' medical records. At the time of the observation there was no staff attending to the medication cart. Registered Nurse (Staff C) came to the medication cart after leaving a resident's room and approached the surveyor. On 7/18/23 at 9:30AM, Registered Nurse, Staff C stated, when asked what he does when he leaves his medication cart to enter a resident's room, he stated, I make sure my cart and computer screen is locked and there is no medication on top of the cart. The Surveyor explained to Staff C, that he left his computer screen opened when he went into the resident's room to check the blood pressure. Staff C acknowledged, leaving the cart open and stated, I was a little nervous. On 07/18/23 at 12:18 PM, the Facility Pharmacist brought Apixaban 5mg for Resident #233 to show the surveyor the medication had arrived from the pharmacy and stated it will be given to the resident right away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 3 of 12 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 07/20/2023 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 Review of the facility's policy titled, Administering Medications revision date 01/2023 states, Medications shall be administered in a safe and timely manner, and as prescribed. Level of Harm - Minimal harm or potential for actual harm Interpretation and Implementation: Residents Affected - Few #3-medications must be administered in accordance with the orders, including any required timeframe. #6-The individual administering the medication must check the label three times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility's policy titled, Security of Medication Cart revision date 01/2023 states: The medication cart shall be secured during medication passes. Interpretation and Implementation: #6-Computer terminals and workstations will be positioned/shielded to ensure that protected health information (PHI) and facility information is protected from public view or unauthorized access. #7-A user may not leave his/her workstation or terminal unattended unless the terminal screen is clear and the user is logged off. Each user must log off at the end of his/her work shift. Review of the undated facility policy titled, Ordering and Receiving Non-Controlled Medications From The Dispensing Pharmacy states medications and related policies are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication orders and receipt. Procedures: A. Ordering Medications from the Pharmacy 1) Medication orders are written on a medication order form i.e. telephone order sheet, reorder form, electronically, etc. provided by the pharmacy, written in the chart by the physician, electronic order, or written on a transfer order form and transmitted to the pharmacy. The written entry includes: a) Date ordered. b) Whether the order is new or a repeat order (refill). If the order is a repeat order (refill), in the prescription number. c) Residents name and other identifying information when necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 4 of 12 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 07/20/2023 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 d) Level of Harm - Minimal harm or potential for actual harm Medication name and strength when indicated. e) Residents Affected - Few Indication for use. f) Directions for use, if a new order, or direction changes to a previous order with indication as to whether a new supply is needed from the pharmacy. g) Name of pharmacy supplier if other than provider pharmacy 2) If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ ordered by peeling the top label from the physician order sheet and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and/or ordered electronically ordered as follows*: a) Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy provider(s). Quantities of medications sent from the pharmacy may vary in accordance with payer status, insurance plan, or law. Examples include Medicare A vs Medicaid, plan limitations on quantities under Medicare Part D, and quantity ordered by the prescriber. Reorder medication three days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. When reordering medication that requires special processing such as Department of Veterans Affairs prescriptions or mail order, order at least seven days in advance of need. b) The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions for use or previous labeling errors. c) The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy. When available and legible, the pharmacy label (including bar - code, if used is pulled and transmitted to the pharmacy. On 7/19/23 at 8:13 AM, medication administration was observed for Resident #92 by Staff D, a Registered Nurse (R.N). The medication administration record documented, Depakote oral tablet delayed release 250 milligrams (Divalproex Sodium). Give 1 tablet by mouth every 12 hours. The blister pack medication label documented, Depakote oral tablet 2 capsules and 125 milligrams each. While preparing the medications for Resident #92, Staff D popped two pills from the blister pack and placed one pill (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 5 of 12 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 07/20/2023 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 each into a medication cup. The surveyor verified with Staff D by asking, How many pills will did you give this resident? Staff D stated one and disposed of the other pill into drug buster. Staff D charted the medications as given. On 7/19/23 at 9:03 AM. In an interview with Staff D, R.N and Staff E, the ADON (Assistant Director of Nursing), it was discussed that one Depakote 125 mg capsule was given to Resident #92, and that there is a difference in the order and a total of 250 mg of Depakote was to be given to the resident. Staff E, ADON stated, Staff D will give the missed dose right now. On 7/19/23 at 10:01 AM, during an interview with the Pharmacist, Staff G, when asked about the order for Depakote for Resident #92, Staff G stated, Depakote can come in different dosages. Nurses are to look at the blister pack label from the pharmacy to administer the right dose. On 7/19/23 at 11:04 AM, during an interview with Staff F, a Nursing Supervisor. The Depakote medication order was discussed and Staff D stated, that [Resident #92] medications were changed recently and there was a PEG (percutaneous endoscopic gastrostomy) before. Most of the medications were liquids. The new orders were to convert to pill form. We asked the pharmacy to replace the blister pack so that Depakote capsules are 1 tablet of 250 milligrams. Record review of Resident #92 revealed, the resident was admitted to the facility on [DATE]. Medical diagnosis included but were not limited to epilepsy (seizures). The minimum data set (MDS), dated [DATE], in Section C: Cognitive patterns, the brief interview of mental status(BIMS) indicated the resident is cognitively intact. The medication administration record revealed, an order for Depakote (Divalproex Sodium) oral tablet delayed release 250 milligrams. Give 1 tablet by mouth every 12 hours for a diagnosis of epilepsy. It started on 7/18/23 at 2100. Depakote (Divalproex Sodium) Sprinkles oral capsule delayed release sprinkle 125 MG. Give 2 capsules by mouth every 12 hours for a diagnosis of seizure. It started on 5/15/23 and was discontinued on 7/18/23 at 12:52 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 6 of 12 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 07/20/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was below five percent, as evidenced by an error rate of 5.71% percent during the medication administration observation. Two (2) medication errors were identified while observing a total of 35 opportunities, affecting Resident # 233 and #92. Residents Affected - Few The Findings Included: 1. 0n 07/18/23 at 8:40 AM during the medication administration observation with Registered Nurse (Staff B). Staff B did not have on the medication cart and was unable to administer one prescribed medication (Apixaban Oral Tablet 5 Milligram (mg) 1 tablet) for Resident # 233. Review of Resident # 233 's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Personal history of other venous thrombosis and embolism, long term (current) use of anticoagulants and Unspecified atrial fibrillation. Review of Resident #233's physician orders for July 2023 revealed, on 7/18/23-7/18/23 Eliquis Oral Tablet 5 MG (Apixaban)-Give 1 tablet by mouth one time only related to personal history of other venous thrombosis and embolism. On 7/18/23-Apixaban Oral Tablet 5 Milligram (mg) (Apixaban) Give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. On 7/18/23 at 9:03AM, Registered Nurse, Staff B stated the last time Apixaban 5 MG was ordered for Resident #233 was 6/17/23, Staff B resent the order for Apixaban 5 mg via the computer today on 7/18/23. The surveyor asked Staff B, when do you usually reorder medications for the residents. Staff B stated, via a Spanish/English translation by the Assistant Director of Nursing (ADON), when the medication is on the last line on the bingo card, we reorder the medication. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented, a Brief Interview for Mental Status (BIMS) score 13 on a 0-15 scale, indicating the resident is cognitively intact. On 07/18/23 at 12:18 PM, the Facility Pharmacist brought Apixaban 5mg for Resident #233 to show the surveyor the medication had arrived from the pharmacy and stated it will be given to the resident right away. Review of the facility's policy titled, Administering Medications revision date 01/2023 states, Medications shall be administered in a safe and timely manner, and as prescribed. Interpretation and Implementation: #3-medications must be administered in accordance with the orders, including any required timeframe. #6-The individual administering the medication must check the label three times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 7 of 12 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 07/20/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled, Ordering and Receiving Non-Controlled Medications From The Dispensing Pharmacy states medications and related policies are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication orders and receipt. Procedures: A. Ordering Medications from the Pharmacy Residents Affected - Few 1) Medication orders are written on a medication order form i.e. telephone order sheet, reorder form, electronically, etc. provided by the pharmacy, written in the chart by the physician, electronic order, or written on a transfer order form and transmitted to the pharmacy. The written entry includes: a) Date ordered. b) Whether the order is new or a repeat order (refill). If the order is a repeat order (refill), in the prescription number. c) Residents name and other identifying information when necessary. d) Medication name and strength when indicated. e) Indication for use. f) Directions for use, if a new order, or direction changes to a previous order with indication as to whether a new supply is needed from the pharmacy. g) Name of pharmacy supplier if other than provider pharmacy 2) If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ ordered by peeling the top label from the physician order sheet and placing it in the appropriate area on the order form provided by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 8 of 12 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 07/20/2023 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 0759 the pharmacy for that purpose and/or ordered electronically ordered as follows*: Level of Harm - Minimal harm or potential for actual harm a) Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy provider(s). Quantities of medications sent from the pharmacy may vary in accordance with payer status, insurance plan, or Residents Affected - Few law. Examples include Medicare A vs Medicaid, plan limitations on quantities under Medicare Part D, and quantity ordered by the prescriber. Reorder medication three days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. When reordering medication that requires special processing such as Department of Veterans Affairs prescriptions or mail order, order at least seven days in advance of need. b) The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions for use or previous labeling errors. c) The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy. When available and legible, the pharmacy label (including bar - code, if used is pulled and transmitted to the pharmacy. 2. On 7/19/23 at 8:13 AM, medication administration was observed for Resident #92 by Staff D, a Registered Nurse (R.N). The medication administration record documented, Depakote oral tablet delayed release 250 milligrams (Divalproex Sodium). Give 1 tablet by mouth every 12 hours. The blister pack medication label documented, Depakote oral tablet 2 capsules and 125 milligrams each. While preparing the medications for Resident #92, Staff D popped two pills from the blister pack and placed one pill each into a medication cup. The surveyor verified with Staff D by asking, How many pills will did you give this resident? Staff D stated one and disposed of the other pill into drug buster. Staff D charted the medications as given. On 7/19/23 at 9:03 AM. In an interview with Staff D, R.N and Staff E, the ADON (Assistant Director of Nursing), it was discussed that one Depakote 125 mg capsule was given to Resident #92, and that there is a difference in the order and a total of 250 mg of Depakote was to be given to the resident. Staff E, ADON stated, Staff D will give the missed dose right now. On 7/19/23 at 10:01 AM, during an interview with the Pharmacist, Staff G, when asked about the order for Depakote for Resident #92, Staff G stated, Depakote can come in different dosages. Nurses are to look at the blister pack label from the pharmacy to administer the right dose. On 7/19/23 at 11:04 AM, during an interview with Staff F, a Nursing Supervisor. The Depakote medication order was discussed and Staff D stated, that [Resident #92] medications were changed recently and there was a PEG (percutaneous endoscopic gastrostomy) before. Most of the medications were liquids. The new orders were to convert to pill form. We asked the pharmacy to replace the blister pack so that Depakote capsules are 1 tablet of 250 milligrams. Record review of Resident #92 revealed, the resident was admitted to the facility on [DATE]. Medical diagnosis included but was not limited to epilepsy (seizures). The minimum data set (MDS), dated [DATE], in Section C: Cognitive patterns, the brief interview of mental status (BIMS) indicated the resident is cognitively intact. The medication administration record revealed, an order for Depakote (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 9 of 12 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 07/20/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm (Divalproex Sodium) oral tablet delayed release 250 milligrams. Give 1 tablet by mouth every 12 hours for a diagnosis of epilepsy. It started on 7/18/23 at 2100. Depakote (Divalproex Sodium) Sprinkles oral capsule delayed release sprinkle 125 MG. Give 2 capsules by mouth every 12 hours for a diagnosis of seizure. It started on 5/15/23 and was discontinued on 7/18/23 at 12:52 PM. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 10 of 12 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 07/20/2023 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 cited during this survey for F755 Pharmacy Services/Procedures/Pharmacist/Records as evidenced by the facility failed to follow Pharmacy procedures for ordering and administering medications for Resident #233 and medications cart security. This deficient practice has the potential to increase the risk of negative resident outcomes and to affect the 303 residents currently residing in the facility at the time of the survey. The findings included: Review of the facility's survey history revealed, during a recertification and complaint investigation survey with an exit dated June 24, 2022, Pharmacy/Services/Procedures/Pharmacist/Records was cited related to the facility failed to provide Pharmaceutical Services to meet the needs of the residents. On 07/20/23 at 01:56 PM, during an interview the compliance officer and the ADON (Assistant Director of Nursing, the ADON/QAPI stated, the Quality Assurance/Quality Assurance Performance Improvement (QA/QAPI) meetings take place the first Wednesday of every month, and they also have quarterly meetings to discuss any issues arising. The ADON stated that the QA committee has members to include the Infection Preventionist, the DON (Director of Nurses), Compliance, Dietitian, the Medical Director, and all of the head departments. The ADON stated, they conduct environmental rounds, interview all the residents to see if they have any concerns. The ADON further stated, We have meetings with the head of the departments. They interview their staff daily so they can identify issues. We also identify issues through incident reports and from past services we had before. We tract and investigate. Based on the finding, we implement the corrective actions based on the issues that were presented. There are reports of what happens in every department. We do medical record review. We do observation, interviews, and record reviews. We interview the nursing staff, interview the residents to see if any issue is arising. We do the morning meetings. We interview staff, do evaluations on them, and monitor the communication log. The open-door policy is always there to let them know that they can always come to us. Every time we've implemented something knew, we have meeting, and we let them know what we are working on. We have weekly falls meeting with the nurses, and the risk management department on incidents. The time frame to correct any problem depends on the issue. For example, we had an environmental problem, I've been monitoring it for the past three to five months. I review the QA again, the documentation, the chart if it relates to the residents. If we do not correct in a certain time, we continue, and do preventive action. I've been reviewing QA on the past citations we have. I monitor wound care closely; we do weekly meetings with the dietary to see if the patient is losing weight. We make sure the residents are using the foley catheter correctly and meet with the medical director to minimize the risks and ensure adequate supervision is provided. If residents are not using oxygen, doctor's orders are followed. We make sure the care plans are followed. In general, I review the care plan, if the call lights are working and followed. The safety for customer care is our main priority. We keep documentation in place and complete them on time. We make sure the pharmacy, medication administration, place of medications, medications carts are in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106031 If continuation sheet Page 11 of 12 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 07/20/2023 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 compliance. We make environmental rounds, to make sure privacy; we interview residents about food, any concerns, food preferences when we make the rounds. We have in-service education training for new nurses, to make sure they are doing the job correctly. We also have in-service education training with all the Certified Nursing Assistant (CNAs) in all aspects. Newly hired wound care nurses received in-service education training as well, to make sure they are doing the wound care properly and follow infection control or prevention procedures. Event ID: Facility ID: 106031 If continuation sheet Page 12 of 12