Health inspection·January 28, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included but not limited to: Oxygen via nasal cannula at 2 liters per minute (l/min) as needed for oxygen saturation (sp02) less than 92% related to Acute and Chronic Respiratory Failure with Hypercapnia. Montelukast Sodium 10 milligrams (mg) one (1) tablet by mouth related to COPD. Theophylline 300 mg extended release- one (1) tablet by mouth every 12 hours for COPD. Gel cushion when in wheelchair for comfort every shift. Record review of Resident #7 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: the resident is Cognitively intact; Functional Abilities section documented the resident is dependent on care, always incontinent of bowel and bladder. Health Conditions documented the resident had one fall with major injury. Section for Medications documented the resident is receiving Antidepressant, Hypnotic, Antiplatelet, Hypoglycemic. Special Treatments and Procedures documented the resident is receiving oxygen therapy. Record review of Resident #7 's Care Plans Reference Date 01/28/2026 revealed: Resident/family/caregiver were educated on fall reduction strategies. Patient will ask for assistance when assistance is needed. Patient will assist staff to maintain a safe environment. Patient will comply with staff instructions Patient will keep bed in low position. Patient will keep environment clutter free. Resident will use call light when assistance is needed. Review resident's medication regimen as needed. Skilled therapy evaluations and treatments as ordered by physician. Staff to assist resident with wheelchair safety to reduce risk of fall and injury every shift. Interview on 01/28/2026 at 4:36 PM, the facility's Transportation Driver (Staff A) stated: On 01/21/26 in the morning on my way to drop the resident [Resident #7] from the facility to a medical appointment close to [local hospital] the following events occurred. -I transported the resident from his room at the facility and took him to the transport vehicle at the entrance of the facility, I placed the resident in his wheelchair on the vehicle lift and raised him up into the vehicle, I secured the wheelchair with four (4) straps to the wheelchair, grounded to the floor of the vehicle, and a belt around his waist secured to the wheelchair. I began driving the resident to his appointment, when I was approximately a block away, I heard a noise at the back of the vehicle, I looked back into the vehicle and saw the resident lying on his left side on the floor of the vehicle, still in his wheelchair. I stopped the vehicle, went to the back where the resident was, I unhooked the seatbelt around the resident's waist, left the resident on the floor, placed the wheelchair in an upright position, and then placed the resident back into the wheelchair and secured the resident the same way I did at the beginning of the trip. Once the resident was secured, I continued to the appointment that was approximately a minute away. When I got to the appointment destination I met the resident's son, I told the resident's son what happened, he spoke to his father, the resident stated he was ok and the son told me it was ok to leave, then I left. I found out later that the resident's son called the facility and let someone at the facility know what happened. After I left the appointment, I came back to the facility. When I returned to the facility I did not report what had happened with the resident in the vehicle. On my way home that day the facility called and told me the resident's son reported to them what had happened and I needed to make a report. The next day I came to the facility to make a report of the events that happened with the resident the day before, after I made my report, I was told that I was on suspension pending the results of the investigation. Currently I am still on suspension. I was only supposed to drop the resident off to his appointment, the resident's son usually spends the day with him after his appointments and bring him back to the facility afterwards.During an interview on 1/28/2026 at 6:27 PM, the Risk Manager, Assistant Administrator (NHA)/Abuse Coordinator revealed that on 01/21/2026 at approximately at 6:30 PM Resident #7's son came to the facility and spoke to Registered Nurse Supervisor (Staff B)-he reported that his dad was at the hospital and on that morning he met the transport driver (Staff A) at his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106094 If continuation sheet Page 2 of 4 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 106094 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156 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 father's medical appointment and the transport driver (Staff A) told him his father had fallen in the vehicle. He spoke with his father, and he was feeling ok at the time and did not have any pain. He continued with his father's medical appointment, during the appointment his father's oxygen saturation went down to 89, but he did not complain of any pain. The staff at the medical appointment called the ambulance and sent the resident to the hospital, his father was later transferred to another hospital. At the hospital he was told his father had a rib fracture and pneumothorax. The resident was then sent from one hospital to another for full evaluation. The son repeated that he did not notice any injury to his father, and he did not think the Transport Driver (Staff A) did anything wrong. On 01/21/26 after the son spoke with the Registered Nurse (RN) Supervisor (Staff B), Risk Manager Assistant NHA/Abuse Coordinator, telephone interviews were conducted with the RN Supervisor (Staff B), the resident's assigned Licensed Practical Nurse (Staff C) and the Transport Driver (Staff A) who worked on 01/21/2026. The Registered Nurse supervisor (Staff B) told the Risk Manager, Assistant NHA and DON exactly what the resident's son told her as mentioned above. The residents assigned Licensed Practical Nurse (Staff C) on 01/21/2026 stated he saw the resident's son in the facility later that day and the resident's son told him that his father fell in the transport vehicle on his way to his appointment. The Transport Driver (Staff A) reported at 8:01 AM on 01/21/2026 he picked the resident up from the facility to take him to his appointment as usual. Prior to leaving the facility, he placed the resident in the vehicle, applying the four straps from the floor to each locking rail where the wheelchair was positioned. Applied the seatbelt across the waist of the resident, then attached to the floor. When he was approximately a minute to the appointment destination, he heard a noise and when he looked back in the vehicle, he saw [Resident #7] falling backwards to the left side. He stopped the vehicle and went to the resident immediately, asked the resident how he was doing, [Resident #7] stated he was not in any pain, he did not notice any blood or injuries. He then took off all the straps to reposition the resident back to a safety position. He then proceeded to the medical appointment with the resident, took the resident out of the vehicle at the medical appointment and waited for the resident's son. When the resident's son arrived, he notified the son about the fall in the vehicle, the son checked his father's body and asked him if he was ok. [Resident #7] stated he was ok and did not complain of any pain. [Resident #7's] son told the transport driver it was ok for him to leave, and he continued with his father into the building to his medical appointment. On 01/23/2026 we interviewed [Resident #7] via telephone at the hospital, he stated that he was feeling better, the driver did position his wheelchair properly with the Four (4) straps and the seatbelt to his waist. The drive to the appointment was approximately 30 minutes, as they were getting close to the medical appointment, the vehicle came to a stop, and he fell backwards in his wheelchair. The driver came to help him immediately and asked him if he had any pain to which his answer was no, the driver then repositioned him in the vehicle and they continued to the appointment where he met his son. During the appointment he started to have shortness of breath and the staff at the appointment sent him to hospital for further evaluation.it was not the Transport Driver's (Staff A) fault, and he has gone to many appointments with the particular (Staff A) and has not had any safety issues with him. We interviewed three residents that were transported by the driver in the past and they stated they did not have any safety concerns/issues with the Transport Driver (Staff A). We tested the Transport Driver (Staff A) within 24 hours of the event, the result was negative for any drug use, reviewed his employee file, his level 2 background screening was up to date. Transport Driver (Staff A) was evaluated and received training from the previous driver, we have never had any issues or concerns related to his driving or safety of the residents he transports. In addition, the Transport (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106094 If continuation sheet Page 3 of 4 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 106094 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Driver (Staff A) has a log that he keeps regarding any issues (maintenance or repair) needing to be completed on the vehicle and notifies administration of any repairs needed. On 01/27/2026 to maintain safety of the vehicle we contacted the company we used for the facility's vehicle maintenance, a Certified Mechanic completed a thorough inspection of the vehicle to include the seatbelt buckles, harness, safety tie downs, as well as the floor mounted locking rails. The Certified Mechanic concluded the equipment was safe and fully operational. We replaced the 4 single straps, lap and shoulder belts as an extra measure. The four (4) single straps, lap and shoulder belt in the vehicle is used to keep the residents safe during transport. We filed a timely, immediate and five-day Agency for Healthcare Administration report, we are still in the process of determining if this event qualifies as an adverse incident and needs to be reported. Despite all safety measures being in place the resident still suffered a fall on 01/21/2026 during transport. The facility had no control of the event taking place. To prevent any future incidents from happening the transport vehicle was inspected and serviced to include new safety equipment. Review of facility policy and procedure titled Safety and Supervision of Residents revision date 10/2025 indicate: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Facility-Oriented Approach to Safety:1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process; Risk Management/Quality Assurance Committee (RM/QA) reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Event ID: Facility ID: 106094 If continuation sheet Page 4 of 4