Inspection·October 13, 2022

F 0550 her in Spanish. Level of Harm - Minimal harm or potential for actual harm On 10/12/22 at approximately 1:00 PM, Resident #124 was observed in bed with television turned to a volume that was inaudible to this surveyor and to the Restorative Nurse that accompanied for the observation. Residents Affected - Few 2). Resident #21 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #21 was not assessed for cognition due to 'resident is rarely/never understood'. The MDS documented that Resident #21 was totally dependent upon staff for all activities of daily living (ADLs), including bed mobility. Resident #21's diagnoses at the time of the assessment included: Anemia, Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Non-Alzheimer's Dementia, Depression, COPD, Encephalopathy, contracture of the right knee, Dysphagia, Acute gastric ulcer. During an interview, on 10/12/22 at 10:53 AM, Staff N, CNA, stated that Resident #21 was 'total care' and was not able to move any part of her upper body by herself. On 10/10/22 11:45 AM, Resident #21 was observed in bed staring at the wall to her left. Upon greeting resident and using her name, Resident #21 responded by smiling and began moving her lower body back and forth and appeared to be excited. It was noted that there were two televisions in the room and that neither one was positioned in a manner that Resident #21 would be able to see. On 10/11/22 at approximately 1:00 PM, Resident #21 was observed in her bed staring at the wall to her left. When Resident #21 was greeted by this surveyor using her name, Resident #21 responded by smiling and began moving her lower body back and forth and appeared to be excited. it was noted that there were two televisions in the room and that neither one was positioned in a manner that Resident #21 would be able to see. On 10/12/22 at 2:22 PM, Resident #21 was observed in her bed with both televisions in the room pointed away from the resident and turned off. On 10/12/22 at approximately 3:00 PM, this surveyor returned to Resident #21's room with the Staff F, Restorative Licensed Practical Nurse (LPN). It was noted that the television on the wall was pointed towards the resident, however the resident's privacy curtain and open bathroom door blocked Resident #21's view of the television. On 10/10/22 at 09:54 AM Resident #15 was observed in activities seated in wheel chair, coloring with other residents. On 10/10/22 at 11:39 AM Resident #15 was observed sitting in wheelchair in dining area with three (3) other residents who were eating. Resident #15 had no lunch tray in front of her, she was sitting at the table watching the other residents eating. At 11:53AM, Activities Aid (Staff I) was observed feeding one (1) resident and the other two (2) residents were eating on their own in the dining area. Resident #15 was taken to her room by Activities Aid (Staff H), no lunch tray was observed in the resident's room, Resident #15 asked staff for her lunch. On 10/10/22 at 12:00PM Resident #15 was observed sitting in wheelchair in her room and asking for food. The lunch cart arrived on the floor (Section 1 north west) at 12:05PM, Resident #15's tray was not on the lunch cart. Business office personnel (Staff J), stated that the resident usually eats in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 2 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0550 Level of Harm - Minimal harm or potential for actual harm the dining room, and proceeded to go check in the dining room for Resident #15's tray. Resident #15 kept asking for her food. Staff J stated the resident's tray was not in the dining room, Staff J proceeded to call the kitchen to request a lunch tray for Resident #15. At 12:22 PM Resident #15 received her lunch tray, the lunch tray consisted of rice, plantains, meat, peaches, juice, and meat sandwich on whole wheat bread, Resident #15 ate approximately 75% of the meal. Residents Affected - Few On 10/11/22 at 11:42 AM, Resident #15 was observed in her room eating lunch, no distress noted On 10/12/22 at 12:07 PM Resident #15 was observed in the hallway in wheelchair, a splint was noted on her right hand. Resident #15 was asked if she had her lunch, shook her head to say yes, several times. Staff J stated that the resident ate in the dining room I checked to make sure where she was there. On 10/13/22 at 12:07 PM Resident # 15 was observed in restorative dining area having lunch. The lunch meal consisted of spaghetti, corn, ground beef, toast, and juice. Resident #15 and other residents in the dining area was being supervised by Restorative Licensed Practical Nurse (Staff F) and two Certified Nursing Assistants (CNAs). Review of the medical records for Resident #15 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Aphasia, Gastro Esophageal Reflux Disease without Esophagitis, Anemia and Cerebral Infarction Review of the Physician's Orders Sheet for October 2022 revealed Resident #15 had orders that included but not limited to: Diet-NAS (No Added Salt) diet, Mechanical Soft (chopped, ground) texture, Regular/Thin consistency, Nutritional Supplement-four times a day for Supplement 4 ounces (oz.) by mouth (P.O.). Medications included: Vitamin B-1 tablet 100 Milligram (MG)-Give 1 tablet orally one time a day for Supplement, Vitamin C Liquid 500 MG/5 ML-Give 5 milliliters (ml) orally one time a day for Supplement Record review of Resident # 15's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns indicated a Brief Interview for Mental Status Score (BIMS) of 5 out of 15, indicating the resident is severely impaired cognitively. Section G for Functional Status indicated resident needs supervision when eating and setup help only. Section K for Nutritional Status indicated the resident has weight loss and is not on a prescribed weight loss regimen. Section Q for Participation in Care Planning indicated the resident's family participated in the assessment. Record review of Resident #15 's Care Plans Reference Date 10/7/2022 revealed: Resident requires limited to total assistance with Activities of Daily Living (ADL's) related to Hemiparesis, Cardiovascular Disease, Weakness, Hypertension, Atrial Fibrillation, Difficulty in Walking, Abnormal Posture, Sarcopenia, Aphasia. Interventions include-Attends Restorative Dining Mon-Fri for lunch, Bilateral 1/2 side rails to assist with bed mobility and promote independence while in bed. May use communication board as resident wishes related to diagnosis: Aphasia. Offer bath of choice, as per schedule and prn. If unable to answer or no answer, provide bath of preference. Shower and/or shampoo hair according to patient preference as scheduled and prn. Therapeutic exercises as ordered. Out of bed daily to wheelchair as permitted. Encourage activities. Passive range of motion and bed mobility provided by floor staff while rendered care. Physical Therapy, Occupational therapy, Speech Therapy (PT/OT/ST) skilled therapies. may use either one full side rail up or bilateral 1/2 rails up while in bed as an assistive device, hand roll to right hand as indicated. Gel cushion while in wheelchair for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 3 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few comfort posture and prevent sacral sliding. Resident has potential for nutrition issues due to therapeutic diet, mechanically altered diet, history of dysphagia, varied by mouth intake. Interventions include-Resident will eat 75% of meals through next review, administer 2.0 calorie supplement per physician orders, administer folic acid, Vitamin b-1, Reno cap, Vitamin c per physician orders, provide diet per physician order: NAS, mechanical soft, thin liquids, record % of intake at each meal, and weigh at least monthly and notify MD of significant weight changes. Interview on 10/12/22 at 08:48 AM Registered Nurse (Staff D) stated, this resident has a puree diet, she feeds herself, sometimes she eats in the dining room and sometimes she eats in her room, she eats most of her food, she really likes the food here. On 10/12/22 at 09:06 AM Registered Nurse Supervisor (Staff E) stated, this resident participates in activities and she will let you know what she wants by motioning yes or no, she is a very pleasant resident, she is very alert but she is unable to communicate verbally, her diet is mechanical soft. When asked where does this resident usually eat her lunch, Staff E reported that the resident eats in the room or sometimes the dining room, with her it's her preference, she tells you by motioning no or yes and pointing to where she wants to go eat, her preference changes every day, when her lunch tray comes to the room, she tells the staff her preference, and they take her to where she wants to go to eat her food. I communicate the resident's dietary orders to the kitchen and request they send her food to her room and then the staff will take the resident where ever she wants to go eat, dining room, activities area etc. On 10/12/22 at 03:41 PM the Director of Nursing (DON) stated: This resident eats in the restorative dining room. On 10/12/22 at 04:19 PM, the Restorative Nurse (Staff F) stated: Monday through Friday the resident has restorative dining for lunch, and it is just for supervision to keep an eye on her while she is eating. Her lunch tray goes directly to restorative in the main dining room, if restorative dining gets canceled for the day, I inform the kitchen to send the resident's tray on the floor where the resident resides, so the resident can eat there. The Restorative CNA would go to the kitchen and inform the kitchen staff or the director of the kitchen, we give them a list of all the residents on restorative dining, they know that the residents on the list we gave them will need their food sent to their rooms. On 10/10/22 and 10/11/22 we did not have restorative dining, so the restorative dining residents ate in their rooms. On 10/12/22 we had restorative dining, and the resident ate in the dining room with us in the restorative dining area. Monday and Tuesday I informed the kitchen staff that there was not going to be any restorative dining, and today we told the kitchen staff that we are going to have restorative dining and all the trays for the residents on restorative dining came to the dining room. Restorative dining was canceled on Monday and Tuesday because the room was kind of warm and it was not comfortable for the residents. Maintenance was working on the air system in the room. The air/chiller is working good today and the room is comfortable. On 10/13/22 at 10:30 AM, Certified Nursing Assistant (Staff G) stated via translator: I work 7:00 AM to 3:00 PM. When asked about Resident #15's care, Staff G stated that the resident eats her breakfast in her room and her lunch in the dining room or her room, dinner she eats in her room and total care is provided for the resident. Review of the facility's policy and procedure titled Promoting and Maintaining Resident Dignity During Mealtimes dated 3/2020 indicated: It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 4 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0550 enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. 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: 106128 If continuation sheet Page 5 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain privacy for one (Resident # 137) out of one resident reviewed for privacy as evidenced by, posting a visible sign on the wall in Resident # 137's room with Personal Health Information (PHI) that included Resident #137's name and hearing aids. There were one hundred-fifty-seven residents residing in the facility at the time of this survey. Residents Affected - Few The findings are the following: Observation on 10/10/2022 at 11:34 AM revealed Resident #137 sitting in her wheelchair, she was alert but with some confusion. Observation revealed a piece of paper attached to the wall located at the head of the resident's bed, the information on the paper attached to the wall included the resident's name and a picture of hearing aids showing instruction with colors indicating the right and left side of the device. While observing the paper on the wall, Resident #137 stated in Spanish language it is for my hearing aids. When asked who put the paper on the wall, Resident #137 stated I don't know. The resident was asked whether a family member might have put the instructions on the wall, but Resident #137 denied it. Resident #137's roommate who heard the conversation stated, the nurse did. Resident #137 re-stated she did not know who put it on the wall. (Photographic evidence) Observation on 10/11/2022 at 10:14 AM, revealed Resident #137 was not in the room, but the paper with Resident #137's name and instruction on how to use hearing aids was still on the wall. (Photograph taken) Observation on 10/12/2022 at 12:09 PM revealed Resident #137 sitting in wheelchair in her room. Resident #137 reported that she only has one hearing aid (seen one on the left side). Resident #137 could not tell where the hearing device for the other side was. The posted paper with Resident #137's name and instructions on how to operate the hearing aids was still on the wall. (Photograph taken). While observing resident, the nurse came into the room to check and left. Observation on 10/13/2022 at 09:20 AM revealed Resident #137 was in bed, she was awake. The paper with Resident #137's name and instructions on how to operate the hearing aids was still posted on the wall. (Photograph taken). Review of Resident #137's face sheet revealed an initial admission date of 12/15/2021 and last day of admission [DATE]. Diagnosis included but not limited to presence of external hearing aid, sensorineural hearing loss, bilateral. Review of the Quarterly Minimum Date Set (MDS) with an assessment reference date (ARD) dated 09/14/2022 revealed hearing coded as adequate with hearing appliances and coded for use of hearing aids. The cognitive section (C0500) documented Resident #137's Brief Interview for Mental Status (BIMS) score as 12 out of 15 indicating the resident is moderately impaired. Review of Resident #137's Physician Order Sheets (POS) dated 07/05/2022, documented order next appointment with ENT (Ear Nose and Throat) physician on 07/07/22 at 9:30 AM for planned hearing test. Review of Resident #137's POS dated 07/07/2022 revealed new order for scheduled appointment with ENT consult for hearing aids evaluation. Record review of Resident #137's progress notes dated 08/03/2022 revealed a Health Status Note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 6 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating: Resident return from appointment with ENT in stable condition with Hearing aids on both ears in place; new order charge every night, return consult in 2 months. social worker notified; order carried out. Interview with Registered Nurse (RN) Staff A, 10/12/2022 at 12:10 PM revealed the resident went recently for a consult, and they kept the hearing aid (right one) in the doctor's office to fix it because it was not working properly. During a follow up interview on 10/13/2022 at 09:21 am Staff A was asked about the paper attached to the wall with Resident #137's name and picture with the hearing aids information. Staff A revealed, they posted the paper on the wall containing the resident's name and hearing aids information when the resident came from consult, for staff to learn how to use them because the resident cannot do it by herself. Staff A stated, the resident is alert, but she cannot do it. Staff A further stated that she does not know who put the paper on the wall, but explained the post is the document that came in the box with the hearing aids. Staff A reported the information should not be there because of HIPPA law and that she received training on privacy of residents and HIPPA law. Staff A immediately attempted to remove the sign off the wall and was asked by the surveyor to wait and call the nurse supervisor. On 10/13/22 at 09:26 AM Staff B, a Certified Nursing Assistant (CNA), revealed when asked who posted the paper with Resident #137's name and instructions for the resident's hearing aids. Staff B stated, I don't know who put it there. Staff B stated she think it was put on the wall to give instructions on how to use the hearing aids and she knows HIPPA and privacy. Staff B stated in Spanish language that she believes the sign is not good under HIPPA law and should not be there. Interview with Staff C, RN Supervisor on 10/13/22 at 09:28 AM revealed she was not aware of the paper put on the wall. Staff C stated she was aware of what is happening with Resident #137's hearing aids and knows that some time ago the doctor kept one of the hearing aids in his office to fix it. Staff C explained the CNAs should be taught verbally. Staff C stated they should take the sign off the wall because she knows HIPPA and that the paper is a violation of Resident #137's privacy. It doesn't have to be there. Interview with the Director of Nursing (DON) on 10/13/2022 at 01:50 PM revealed the facility started in service training with staff about privacy and HIPPA law. The DON stated the sign should not be posted with information where it was visible the resident's name and the hearing aids she is using. The DON stated they have no idea who put the sign on the wall. The DON was asked about the facility's practice on communicating with staff about resident's care and in a case, staff needed to be trained on certain aspects of the resident's care; the DON reported that staff nurses and supervisors will make all staff aware of what is needed for all residents, and they all are educated on residents' rights and the right to privacy. The DON revealed that even when the family wants to put a sign about anything the staff should educate the family on resident rights to privacy. Review of the facility's Policy and Procedures for Resident Rights dated 03/01/2021 revealed: Policy: It is the policy of the facility to provide Resident Rights in accordance with State and Federal regulations. Procedure: The facility will follow the Resident Rights as follows: 15. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 7 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide meaningful activities for 1(Resident #21) out of 2 residents reviewed for activities. Residents Affected - Few The findings included: On 10/10/22 at 11:45 AM Resident #21 was observed in bed, staring at the wall to her left. Upon greeting resident and using her name, Resident #21 responded by smiling and began moving her lower body back and forth and appeared to be excited. It was noted that there were two televisions in the room and that neither one was positioned in a manner that Resident #21 would be able to see. On 10/11/22 at approximately 1:00 PM, Resident #21 was observed in her bed staring at the wall to her left. When Resident # 21 was greeted by the surveyor using her name, Resident #21 responded by smiling and began moving her lower body back and forth and appeared to be excited. It was noted that there were two televisions in the room and that neither one was positioned in a manner that Resident #21 would be able to see. On 10/12/22 at 8:39 AM, Resident #21 was observed in bed sleeping. On 10/12/22 at approximately 2:22 PM, Resident #21 was observed in her bed with both televisions in the room pointed away from the resident. Review of Resident # 21's clinical records revealed: Resident #21 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #21 was not assessed for cognition due to 'resident is rarely/never understood'. The MDS documented that Resident #21 was totally dependent upon staff for all activities of daily living (ADLs), including bed mobility. Resident #21's diagnoses at the time of the assessment included: Anemia, Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Non-Alzheimer's Dementia, Depression, COPD, Encephalopathy, contracture of the right knee, Dysphagia, Acute gastric ulcer. Resident #21's care plan, initiated on 07/08/21 and most recently revised on 07/18/22, documented, [Resident's name] would benefit from in room visits due to impaired skin integrity with open area. [Resident's name] unable to attend act group R/T (related to) deteriorating physical condition. The goal of the care plan was documented: [ Resident's name] will receive in room visits for socialization, cognitive stimulation, and to increase stamina 3 X (three time) weekly or as tolerated through the next review date . will be provided with 1:1 (one-to-one) room visits 2-3 times a week to decreased isolation.07/08/21 and most recently revised on 07/18/22 with target date of 01/05/23. Interventions in the care plan included: to address resident by his/her name with each interaction.Identify self and anticipated need before provide care. Provide activities to increase stamina and time awake. Provide sensory stimulation such as radio, music, TV. Staff will provide support and encouragement through room visits. Staff will speak slowly and clearly always facing resident and will maintain eye contact within line vision. Talk/touch/approach as appropriate. There was no documentation in the resident's record supporting that the resident had a skin condition that prohibited her from being out of bed. During an interview, on 10/12/22 at 4:30 PM, with the Activities Director and Staff L, Activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 8 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Aide, when asked about Resident #21 having any condition that prevents her from getting out of bed and going to Activities, Staff L stated that the resident was contracted in the lower body and not able to get out of bed. The Activities Director and Staff stated that they do one to one visit with Resident #21 three times per week. When asked what Staff L did with Resident #21 during the one-to-one visits, Staff L stated, I do hand massages, we reminisce about family. When asked how much time was spent with Resident #21 for the activities that she described, Staff L replied, 5-10 minutes each time. It was determined that the Activities staff spent less than one half hour with Resident #21 based on the Activities staff stating that the do massage for a few minutes, reminiscing about family, and turning the television on for the resident. Staff L further stated that she goes to each residents' room that she is assigned, including Resident #21, to turn on the television, and I ask them if they need anything. On 10/13/22 at approximately 8:00 AM, the Activities Director provided documentation of one-to-one room visits with Resident #21 and stated that Therapy was going to reassess the resident to see if she can safely be taken out of bed. The Activities Director further stated that if they can safely get the resident out of bed, they would remove her from one-to-one and she would be able to participate in activities. When asked about the most recent assessment of Resident #21 by Therapy, the Activities Director stated that she did not know. During observation and interview on 10/13/22 at 8:40 AM, Resident #21 was observed out of bed and in a lounger. Staff F, Restorative Licensed Practical Nurse (LPN) was asked when the last time was that the resident had been assessed by therapy for getting out of bed Staff F replied that she did not know. The Restorative LPN (Staff F) further stated, when I came in this morning, I talked to activities and therapy is going to assess her with activities to see what would be appropriate. During an interview, on 10/13/22 at 9:44 AM, with the Director of Rehabilitation, when asked about Resident #21, the Director of Rehab stated: She was on PT (Physical Therapy) and OT (Occupational Therapy) at the beginning of the year, we discharged her on 02/14/22 and she was endorsed to restorative for range of motion and bed mobility. We usually do a screen whenever they have any problems with sitting and mobility. She was in a high back wheelchair. I did one recently for a Geri-chair. When we pick up the resident for skilled services and endorse them to restorative it is for mobility, bed mobility and range of motion. Restorative would be responsible for getting them out of bed. We assigned her a chair on admission as part of our screening. Whenever she was admitted was when she got her chair, the rest is up to restorative. She was assessed on 2/12/22 for PT and OT and at that time was when she got her wheelchair. Review of the facility's policies and procedures for 'Activities', dated 06/2020, the policy states, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility-sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the community. Section 2, of the policy documented, Activities will be designed with the intent to: a. Enhance the resident's sense of well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 9 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0679 b. Level of Harm - Minimal harm or potential for actual harm Promote or enhance physical activity. c. Residents Affected - Few Promote or enhance cognition. d. Promote or enhance emotional health. e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence. f. Reflect resident's interests and age. g. Reflect cultural and religious interests of the residents. h. Reflect choices of the resident. Section 3 of the policy documented, ADL-related activities, such as manicures/pedicures, hair styling, and makeovers, may be considered part of the activities program. Section 4 of the policy documented, Activities may be conducted in different ways: a. One-to-one Programs b. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c. Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. Section 8 of the policy documented, Activities will include individual, small and large group activities, as well as: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 10 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0679 a. Level of Harm - Minimal harm or potential for actual harm Indoor and Outdoor activities. b. Residents Affected - Few Activities away from the facility. c. Religious activities. d. Exercise programs. e. Community Activities. f. Social Activities. g. In-room activities h. Individualized Activities i. Educational Programs. Section 9 of the policy documented, Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 11 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility flailed to provide adequate supervision to prevent potential aspiration for 1 (Resident #6) of 5 residents sampled for nutrition review. The facility had 157 residents residing in the facility at the time of the survey. The findings included. During the observation of the lunch meal on 10/10/22 at 11:30 PM, it was noted that Resident # 6's lunch tray was served in the room. Further observation noted that the meal card located on the food tray documented: Aspiration Precaution, Honey Thick Liquids, and Pureed Diet with Ground Meats. During the meal observation from 11:45 AM to 12:30 PM it was noted that Resident #6 had some cognitive impairment, was able to self-feed, however, would take large bites of pureed foods. It was also noted that during the 45-minutes observation no staff entered the room to supervise or assist the resident with the consuming of the lunch meal. It was also noted that the resident had a container of blue Gatorade ® and a 16-ounce container of thin water on the food tray and was noted to be drinking from both. During a second meal observation, during the breakfast meal conducted on 10/11/22 at 8:15 AM, and a third meal observation conducted during the lunch meal on 10/11/22 at 11:45 AM it was again noted that the meal trays were delivered to the room of Resident #6. Review of the meal tray cards still documented Aspiration Precautions and Honey Thick Liquids. During the observations it was again noted that no staff entered the room of Resident #6 to provide supervision or assistance with the meals. There remained a container of Gatorade ® (thin liquid) and 16-ounce water container of which the resident was drinking from during the meal observations. During the review Resident #6's clinical record on 10/11/2022 to 11/12/2022 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to Sclerosis, Degenerative Nervous System Disease, COPD, and Dysphagia, Following CVA, and Altered Mental Status. Current Physician Orders Sheet indicated order dated 10/10/2022 - Frazier Water Protocol (allows patients with dysphagia (swallowing problems) to drink water that is not thickened, between meals). Order dated 7/16/2022 and 9/8/2021 indicated- Strict Swallow Aspiration Precautions In Place. Order dated 10/12/22 indicated- No Added Salt /Puree Diet /Honey Thick Liquids. Review of Restorative Nursing Program dated 09/08/2022 documented: Dining during lunch 5 times per week. Review of the Quarterly Minimum Data Set( MDS) dated [DATE] documented the resident Brief Interview of Mental Status (BIMS) as 12 out of 15 indicating the resident is moderately impaired. The section for functional status documented Eat = Supervision with meals. Review of current Care Plan dated 11/01/2021 noted: Risk for Aspiration related to Dysphagia/Requires staff to supervise during all oral intake/Requires Aspiration Precautions. Review noted interventions noted only to take small bites/small sips and swallow slowly. No documentation for enrollment into the Nursing Restorative Dining Program. During an interview with the Licensed Practical Nurse (LPN), Restorative Nursing Supervisor on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 12 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 10/13/22, it was discussed by the surveyor that the resident is not attending the Restorative Dining Program and not receiving strict aspiration precautions supervision during meals. The Restorative Nursing Supervisor stated she was unaware that there was a current physician's order for Nursing Restorative Dining and Strict Aspiration Precautions with all meals. The Restorative Nurse revealed that the resident is not enrolled in the Restorative Dining program, and the Restorative Dining Program is only Monday to Friday, for the lunch meal only, and no weekends. The Restorative Nursing Supervisor further revealed that she does not know how Resident #6 receives Restorative Dining on weekends and during the breakfast and dinner meals. The Restorative Nurse submitted a facility Policy & Procedure (P & P) for Restorative Dining on 10/13/22 which was reviewed by the surveyor. Following the review of the P &P it was discussed with the restorative Nurse that the following were not included in the P & P: < What staff will be responsible to assess residents for admission into the program. < No documentation of the meals and days that the program will take place (currently on lunch meal). < NO documentation how the program will continue meals on days that the program is not in place (currently on Monday - Friday). < How residents are evaluated for the continuance of the program by nursing and dietary departments. On 10/13/22 and an interview was conducted with the facility's Speech Language Pathologist (SLP) who submitted a SLP Evaluation and Plan of treatment dated 10/13/22 for Resident #6. A review of the evaluation noted documentation to include: < Lingual Function: Impaired < Overall Ability: Mild Swallowing Ability < Liquids Assessed: Honey Thick Liquids < Solids Assessed: Mechanical Soft/Pureed Consistency < Supervision: Supervision With Oral Intake <Strategies: Universal Feeding Precautions During observation of the lunch meal of 10/13/2022 and lunch meal of 10/13/2022 it was noted that the resident was seated in the Restorative Dining in the First Floor Main Dining Room and was being supervised one to one by nursing staff for physician ordered aspiration precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 13 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide physician ordered thickened liquids to meet the needs of 1 (Resident #6) of 5 residents sampled for nutrition review. The findings included: During the observation of the lunch meal on 10/10/2022 at 11:45 AM, it was noted that the lunch tray was served to the room of Resident #6. A review of the lunch tray ticket documented; Pureed/ Ground Meats, **Aspiration Precautions and ** Honey Thick Liquids. Further observation of the meal noted that a 16-ounce container of ice water (thin liquid) and a 16-ounce container of blue Gatorade® (thin liquid) was located on the over-bed table with the meal tray. Further observation noted that the resident was drinking both the water and Gatorade® thin liquids. A second meal observation of the breakfast meal of 10/11/22 at 7:30 AM again noted the meal tray served to the room of Resident #6 and a 16-ounce container of thin water and 16-ounce container of Gatorade® were located on the over-bed table next to the meal. The resident was noted to have some cognitive confusion and was noted to be drinking from the water and Gatorade® containers. Review of Resident #6's clinical record revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to Sclerosis, Degenerative Nervous System Disease, COPD, and Dysphagia, Following CVA, and Altered Mental Status. Current Physician Orders Sheet indicated order dated 10/10/2022 - Frazier Water Protocol (allows patients with dysphagia (swallowing problems) to drink water that is not thickened, between meals). Order dated 7/16/2022 and 9/8/2021 indicated- Strict Swallow Aspiration Precautions In Place. Order dated 10/12/22 indicated- No Added Salt /Puree Diet /Honey Thick Liquids. Review of current Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident Brief Interview of Mental Status (BIMS) as 12 out of 15 indicating the resident is moderately impaired. The section for functional status documented Eat = Supervision with meals and section K for Swallowing and Nutritional Status documented that the resident required Thickened Liquids. Review of the Care Plan dated 9/23/22 indicated: Problem of Nutrition Risk - intervention to assess chew/swallow strategies. Further review of the care plan did not include documentation of the physician's order for Honey Thick Liquids and failed to document the approaches for Strict Aspiration Precautions. On 10/12/22 the issues of the failure to provide physician ordered Honey Thick Liquids for Resident #6 was reviewed with the Director Of Nursing (DON). Following the review, the DON clarified that the physician ordered on 10/12/22 for the resident to remain on No Added Salt/Pureed/ Honey Thick Liquids. The DON also requested the Resident #6 to be re-assessed by Speech Language Pathology (SLP) for Dysphagia/Swallow. On 10/13/22 the SLP reviewed the assessment with the surveyor. The SLP stated that Honey Thick Liquids are provided and the order for Frazier Free Water Protocol would remain. The SLP stated that the protocol allows the resident to drink water between meals beginning a minimum of 30 minutes after meals. The resident was also required to sit upright and use appropriate swallowing strategies. It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 14 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was further discussed with the SLP that the resident was not following the Frazier Free Water Protocol based on the observations of the resident drinking thin water and thin Gatorade® with meals. Also noted was that strict swallow aspiration precaution was not being followed by staff for Resident #6 during meals and were not included in the care nutritional/swallow care plan. Review of the facility's current Policy & Procedures: Resident Required Thickened Liquids indicated: Procedure #2: Facility will not provide residents on thickened liquids with a water pitcher/thin liquid at bedside. Review of the Free Water Protocol documented Guideline: Patient is allowed to drink water between meals, beginning a minimum of 30 minutes after meals. Event ID: Facility ID: 106128 If continuation sheet Page 15 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow a physician ordered therapeutic diet (fluid restriction) for 1 (Resident #94) out of 5 residents sampled for nutrition review. The findings included: During the observation of the lunch meal on 10/10/22 at 12:30 PM, it was noted that the meal tray was served to the room of Resident #94. Observation of the lunch meal ticket on the meal tray documented a Mechanical Soft Diet and Fluid Restriction. Further observation of the lunch meal ticket revealed no amounts of fluids to be served were documented on the ticket. Observation of the meal noted that 8 ounces of water, 6 ounces of coffee, and 6 ounces of juice were served for a total of 600 ml (milliliters). It was also noted that the resident had an additional 6 ounces (180 ml) of water on the bedside table with the meal tray. During the meal observation it was noted that there was no supervision or assistance given to Resident #94. A second meal observation was conducted of the breakfast meal of 10/11/22 at approximately 8:10 AM and again the tray was served to the room of Resident #94. Review of the breakfast meal ticket also documented Fluid Restriction, however the amounts of fluids to be served with the breakfast meal were not documented on the meal ticket. It was noted that 6 ounces orange Juice, 6 ounces of coffee, and 8 ounces of milk were served for a total of 600 ml. It was also noted that a 16-ounce container of ice water was on the resident's over-bed table. Interview conducted with the resident at the time of the meal observation revealed some cognitive confusion however the resident stated to have no knowledge of the fluid restriction and would drink the water from the contained during the day. During the meal observation it was noted that there was no staff supervision or assistance given to Resident #94. A review of Resident #94's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Hypo-Osmolality-Hyponatremia, Cerebral Infarction, DM 2. COPD, Calorie-Pro Malnutrition, and Dysphagia, Dementia. Review of the current Physician Orders indicated: No Concentrated Sweets/Mechanical Soft/Chopped Texture. Order dated 8:30/2022- Speech Therapy: 3-5 times per week for 30 days. Order dated 9/1/2022 - Fluid Restriction 1.2 Liters /Day. Review of the Minimum Data Set (MDS) dated [DATE] indicate the resident's Brief Interview of Mental Status (BIMS) score as 6 out of 15 indicating the resident has severe cognitive impairment. Section G for Functional status indicated the resident required supervision with meals. A review of the current Care Plan for Resident #94 dated 8/15/22 failed to document an approach under Nutrition/Hydration for the following of the physician ordered fluid restriction and the specific fluid restriction order. Review of the October 2022 Medication Administration Records (MAR) did not have the specifics noted for the resident's fluid restriction and nursing staff were not documenting as per shift. On 10/12/22 at approximately 9:00 AM, the issues of the fluid restriction were reviewed with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 16 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director of Nursing. Following the nursing review, it was revealed that the 9/1/22 Fluid Restriction should have been clarified by nursing to obtain the total amount of fluid restriction per 24 hours and the breakdown of the restriction between nursing and dietary. On 10/13/22 the Director of Nursing submitted to the surveyor a clarified physician order dated 10/12/22 for Resident #94 that included the following: * Fluid Restriction: 1200 ml per day * Dietary to provide 720 ml for Breakfast, Lunch, and Dinner meals * Nursing to provide 210 ml 7-3 shift * Nursing to provide 210 ml 3-11 shift * Nursing to provide 60 ml 11-7 shift * Total of 1200 ml /day Review of the facility's Policy & Procedure dated 08/07/2020 for Fluid Restriction review noted: Guidelines: #2 - A specific physician's order for the fluid amount to be provided in a 24-hour period is required. The order is to be written as a range of fluid by cc. #3 - When an order is received for a fluid restriction, the dietitian confers with the nursing department to determine how much fluid each department is to provide. #5 - The Fluid Restriction Worksheet is used to outline the division of fluids - by department, meal, and shift. The original form is placed in the dietary section of the medical record. #6 - The amount of fluid to be given with meds on each shift is written of the Medication Administration Record (MAR). This will be part of the Physician's Order Sheet (POS) and the permanent MAR for the length of the ordered restriction. During an interview conducted with the facility's Registered Dietitian On 10/13/22 noted to state that the facility policy and procedure was not followed to include that the dietary department was notified via a dietary slip of Resident #94 fluid restriction. The Dietitian further stated that the physician's fluid restriction would have been clarified and a new restriction obtained. Further stated that once the order was clarified a calculation of dietary and nursing fluid allotments would have been conducted and nursing notified of a change to the resident's Medication Administration Record (MAR) for fluid per shift. The dietitian also submitted to the surveyor the clarified dietary tray tickets to include documentation of a 1200 ml Fluid Restriction and documented 240 ml of fluids per shift and a clarified MAR fluid restriction per shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 17 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview it was determined that the facility failed to store, prepare, serve food in accordance with professional standards for food service safety. The issues included: failure to protect food from contamination, failure to maintain sanitizing chemical solutions, failure to maintain refrigeration and ice machines, and proper cleaning and maintenance of food preparation equipment. The findings included: 1) During the original food service observation tour conducted in the main kitchen on 10/10/22 at approximately 9:00 AM accompanied with the facility's Food Service Manager (FSD), the following were noted: (a) Upon entrance into the kitchen it was noted that 4 facility staff (Staff P, Q, R, and S) were working within food preparation and food serving areas. Further observation noted that there 4 staff were wearing dangling ear and neck jewelry. Interview with the FSD at the time of the observation revealed that she was not aware that jewelry falling into food is a form of food contamination and requested that the 4 staff remove their jewelry while working in these areas. (b) Observation of the juice dispensing machine noted that the dispensing gun nozzle was being stored in soiled, stagnant water when not in use. Interview with the FSD at the time of the observation revealed that she was unaware that the gun dispensing nozzle was required to be stored in moving clean water of cleaned and sanitized and kept dry after each use. (c) During the observation of the food preparation sink area it was noted that the wall area was in disrepair and had large area of peeling paint that were located directly above the sink area. It was discussed with the FSD at the time of the observation that there was the potential for pieces of the wall and peeling paint to fall into foods being prepared in the sink area and could result in food contamination. The facility's Food Service Manager was informed by the surveyor that the preparation sink area should not be utilized until wall repair and painting was completed. (d) During the observation of the exhaust hood it was noted that the exterior of the hood, wall vent, and surrounding wall area had dust and laden with dirt. It was discussed with the FSD at the time of the observation that the dust could potentially fall into foods being prepared by the commercial food preparation equipment that are located directly beneath the exhaust hood. The surveyor requested that the dust/dirt be removed, and wall area be cleaned prior to the next meal preparation. (e) During the observation of the Reach-in refrigerator #1 it was noted that the 18 food storage shelves located within the unit were rusted and had areas of the plastic coating being worn off. It was also noted that the internal temperature of the unit was recorded at 50 degrees Fahrenheit (F), and the exterior of the unit had heavy build-up of condensation that was dripping back into the cavity of the refrigerator. It was discussed with the FSD at the time that the internal shelves (18) required repair or replacement. It was also discussed that the internal temperature of the unit (50 F) was far above the regulatory requirement of 41 degrees or higher. It was also discussed that high temperature was causing the heavy condensation build-up and that the unit should be monitored and if continued, use of the unit will be ceased until it is working properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 18 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 - Some (f) Observation of the commercial ice machine noted that the entire exterior was covered with a heavy build-up of condensation. Further observation of the unit noted that when opening the door to the ice reserve the condensation was dripping down the exterior of the unit and dripping into the fresh ice reservoir. It was discussed with the FSD that the fresh ice was potentially being contaminated from the dripping condensation and the unit should not be used until it is working properly without the potential of contamination from the exterior condensation. (g) At the request of the surveyor a chemical test of the rag bucket solution (Bucket's #1 and #2) was conducted by the FSD. During the chemical test of the cleaning water solution, it was noted both cleaning rag buckets were recorded at over and above 400 PPM of Quaternary Ammonia (QUAT) chemical solution. It was discussed that the regulatory requirement of the QUAT was 200 PPM. It was further discussed that the chemical solution being left on the surfaces of food preparation surfaces, food serving surfaces and food preparation equipment was potentially toxic. It was further discussed that the chemical company servicing the department be notified to titrate the chemical solution down to the regulatory requirement of 200 PPM. (h) At the request of the surveyor a chemical test of the dish machine final rinse was conducted by the FSD. During the chemical test of the final rinse solution, it was noted to be recorded at over and above 200 PPM of chlorine bleach chemical solution. It was discussed with the FSD that the regulatory requirement of the chlorine bleach solution was 50-100 PPM. It was further discussed that the chemical solution being left on the surfaces of residents' dishes and glassware was potentially toxic. It was further discussed that the chemical company servicing the department be notified to titrate the chemical solution down to the regulatory requirement of 50-100 PPM. (i) During observation of the commercial floor mixer it was noted that the exterior was heavily rusted in areas that were directly above the mixing bowl area. It was discussed with the FSD that this was a potential that each time the mixer is used the potential for pieces of rust to fall into the mixing bowl and potentially result in food contamination. (j) During observation of the walk-in refrigerator it was noted that the internal walls of the unit had large areas of peeling paint. It was discussed with the FSD at the time of the observation that there was the potential of peeling paint to fall into foods being stored within the unit. 2) During a subsequent tour of the dietary department on 10/11/22 at 11:00 AM, the following were noted: (k) Observed Staff T to be working in the food preparation and serving area. Further observation of Staff T noted a heavy beard and moustache which was not covered by a beard/moustache guard. The surveyor requested to the FSD that Staff T don a beard/moustache guard prior to continued work in the food preparation and serving areas. (l) During the observation of lunch tray preparation, the surveyor requested that food temperatures be taken with the facility's calibrated thermometer. As a result of the temperature testing, it was noted that 4 servings of thickened milk were recorded at 51 degrees F. It was discussed with the FSD at the time of the observation that cold foods are required to be held the regulatory temperature of 41 degrees F or below. The surveyor recommended that the milk serving be discarded. 3) During a routine observation of Resident #142 on 10/12/22 at 12 PM, it was noted that a duffle bag was in the room near the resident. The surveyor asked the Certified Nursing Assistant (CNA) about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 19 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the bag who stated that is the bag she is taking with her to the dialysis center. The CNA stated that the bag was dropped of approximately 30 minutes ago and stated that the bag contained food that the resident will eat at the dialysis center. At the request of the surveyor the paper bag that contained the food included: tuna fish sandwich, cranberry drink, canned fruit, and graham cracker. It was also noted that the perishable food (tuna fish) was not contained in an insulated bag and there was no frozen commercial ice brick to ensure that the food remained at the regulatory temperature of 41 degrees F or below for transport to the dialysis center and storage at the dialysis center. The CNA also stated that the food is stored in only a brown paper bag for each dialysis day (3 times per week). The bag was brought to the administrator and Food Service manager who revealed that they were aware that the perishable food required cold food maintenance but failed to store foods properly for Resident #142. Event ID: Facility ID: 106128 If continuation sheet Page 20 of 21 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166 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 problem prone area related to repeated deficient practices for Activities Meet Interest/Needs Each Resident (F 679). As evidenced by the facility failed to provide meaningful activities for Resident #21. F 812 Food Procurement Store/Prepare/Serve/Sanitary (F 812), the facility failed to follow sanitation procedures in the kitchen and failed to ensure food was kept at the proper temperature for a resident going to dialysis treatment (Resident # 142). This deficient practice has the potential to affect 147 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 02/20/2020, F 679 Activities Meet Interest/Needs Each Resident was cited related to the care plan for a resident with no planned interventions to address activity needs and or preferences. F 812 for Food Procurement Store/Prepare/Serve/Sanitary was cited due to staff failure to sanitize his/her hands before assisting a resident to eat. During an interview with the facility's Administrator and the Director of Nursing on 10/13/2022 at 3:25 PM. The Administrator stated that the QAPI (Quality Assurance and Performance Improvement) meetings are held on the last Thursday of each month. The Administrator stated that for the Activities deficiency they will provide education training for Activities Staff to provide meaningful activities to the residents that prefer to stay in their room. Activities staff should go to their rooms and provide individualized activities. For Food Procurement education training for dietary staff to prevent the issues with the food not properly stored for residents going out of the facility for dialysis treatment how to follow sanitation procedures in the kitchen. The Director of Nursing stated immediately after the Administrator knew about the issues with food storage, he sent a staff to buy insulated lunch bags for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 21 of 21