Inspection·May 8, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/08/25 at 01:36 PM, the Director Of Nursing (DON) stated I have been the Director of Nursing at this facility since January this year. Per facility policy, every resident is provided with access to a phone unless they have declined its use. In shared rooms with three or four residents, phone access may be shared among them. To date, there have been no complaints regarding non-functional phones. When an issue is identified, the maintenance department is promptly notified to repair or replace the device as needed. Incoming calls are directed by the facility operator to the appropriate nursing station or nursing staff and then they would direct the call to the resident's room. Each nursing station is equipped with a portable phone accessible to both residents and nursing personnel for communication purposes. At an interview on 05/08/25 at 02:28 PM, the Maintenance Director revealed, I have served as the Director for four years, overseeing monthly operations. We ensure that any resident's telephones are promptly replaced, and if the issue lies with the phone line, we contact the service provider directly. Each floor maintains a dedicated maintenance log. We are actively working to resolve these issues by keeping a daily record of non-functioning phones and tracking the ones we've successfully repaired. Review of the facility policy and procedure regarding resident rights 03/01/21, states the resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 2) Observation on 05/06/2025 at 10:05 AM of Staff J, Registered Nurse (RN) performing medication administration revealed; Staff J, RN prepared Resident # 152's medications. The door to Resident #152's room was open and from the hallway the resident was seen seated in his room. Residents Affected - Few Staff J, RN entered Resident # 152's room with the prepared medications, did not close the door, identified the resident, did not close the privacy curtain and administered the medications. Interview on 05/06/2025 at 10:32 AM Staff J, RN was asked about professional standards related to privacy during medication administration. Staff J, RN revealed the door, and the privacy curtain should have been closed. Staff J, RN stated: That is one of the most important things. On 05/08/2025 at 03:43 PM, the Assistant Director of Nursing (ADON) was informed of the identified privacy concerns. The ADON revealed staff had made her aware of the identified privacy concerns. Based on observations, records reviewed and interviews, the facility failed to ensure privacy of confidential information on one (2 North) out of two Nursing Stations on the facility's 2nd floor, as evidenced by observation of an unattended unlocked computer screen with residents' information visible. 2) Failed to provide privacy during medication administration for one (Resident # 152) out of five residents observed during medication administration. There were 185 residents residing in the facility at the time of the survey. The findings included: 1) On 05/05/2025 at 11:49 AM, observation on the 2nd floor of North Nursing Station revealed an unattended unlocked computer screen with visible resident formation. (Photographic evidence). On 05/05/2025 at 11:53 AM, Staff E, Registered Nurse (RN) was notified of the unattended unlocked computer screen. Staff E, RN revealed the supervisor was currently logged in and stated: I will notify the supervisor. On 05/05/2025 at approximately 11:57 AM, Staff G, RN Supervisor was asked about the facility's protocol related to protecting and securing residents' information. Staff G stated: The computer screen should be off when unattended. I left it open by mistake because I was rushing to attend to residents. Review of a Policy titled; HIPAA Security Measures date implemented: 6/2020 revealed Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and or records that are in electronic format. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one (Resident # 184) out of three sampled residents; as evidenced by the resident was discharged to an Assisted Living Facility, and the MDS was coded to indicate that the resident was discharged to a Short-Term General Hospital. Residents Affected - Few The findings included. Review of Resident # 184's clinical records revealed the resident was admitted to the facility on [DATE] from a Short-Term General Hospital (acute hospital). Medical diagnosis includes Traumatic Subdural Hemorrhage without loss of consciousness, subsequent encounter and Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. Review of the Physician's Discharge summary dated [DATE] documented: The patient will be discharged to [facility name] Assisted Living Facility (ALF) on 4/16/2025. Review of Social Services Note dated 04/17/2025, documented: Resident was discharged to [facility name] ALF. Review of Resident # 184's MDS Discharge assessment - return not anticipated Assessment Reference (ARD) Date/Target Date: 04/16/2025 revealed in the section for cognitive pattern that Resident #184 is cognitively intact. The Discharge Status Section coding indicated the resident was discharged to a Short-Term General Hospital (acute hospital). During an interview on 05/08/2025 at 03:26 PM the Assistant Director of Nursing revealed Resident # 184 was discharged to an ALF as planned on 04/16/2025. During an interview on 04/08/2025 at 3:35 PM, The MDS and Care Plan Coordinator (Staff K) revealed Resident # 184 was admitted from a hospital on [DATE] and was discharged to an ALF on 04/16/2025. Staff K was shown Resident #184's Discharge MDS; Staff K acknowledged the incorrect coded information and stated: I did that one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to implement fall risk and seizure care plans for three residents (Resident #106, Resident # 88 and Resident #56) out of three sampled residents; as evidenced by observations of missing padding on one side rail for Resident #106, Resident #88, and Resident # 56. There were 36 residents with orders for padded side rails at the time of this survey. The findings included: Resident # 88: On 05/05/25 at 9:58 AM, Resident #88 was observed in bed the left side rail was in the upward position and padded. The right-side rail was in the down position. Two staff members were in the room tending to other residents. On 05/08/2025 at 12:37 PM Staff E, Registered Nurse (RN) was informed about the padding that was not on side rail. Staff E, RN acknowledge the concern and stated, I received an in-service yesterday about it. Record review of Resident #88's demographic sheet revealed the resident was admitted on [DATE] with diagnosis that included: Epilepsy. Record review of an Annual Minimum Data Set (MDS) reference dated 4/23/25 revealed a Brief Interview of mental Status (BIMS) score of 6 out of 15 meaning Resident # 88 is severely impaired cognitively, has no potential indicators of psychosis, and dependent on transfers. Record review of a care plan initiated on 06/08/2021 and revised on 08/27/2021 revealed Resident #88 has the potential for complications related to seizure disorder with a goal to minimize the risk of injury during seizure through the next review date. The interventions included: Bilateral half side rails while in bed with padding for safety related to diagnosis: Seizures. Record review of a Physician Orders Sheet revealed an order dated 11/18/2024 for bilateral half side rails while in bed with padding for safety related to diagnosis: Seizures for every shift related to and monitor for placement/safety. Resident # 56: On 05/06/25 at 9:45 AM Resident # 56 was observed in bed with both side rails in the upward position and the left side rail was not padded (photo evidence). There were no staff members in the room. During an interview on 05/06/25 at 9:45 AM, (with translation assistance by Staff H, Registered Nurse RN MDS coordinator) Staff C, Certified Nursing Assistant (CNA) was asked if paddings are required on both side rails; Staff C, CNA stated, I know the padding should be on both side rails to prevent injury but I removed it and left the room to get something and forgot to replace it. Record review of Resident #56's demographic face sheet revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that include: Seizures, Muscle Wasting and Atrophy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a Quarterly MDS reference dated 2/10/25 revealed Resident #56 is moderately impaired cognitively and dependent on transferring. Record review of a care plan initiated 8/31/2023 and revised on 08/192024 revealed Resident # 56 is at risk for falls related to diagnosis that include: Alzheimer's disease and Seizures with a goal to be free of fall related injuries by next review date. The interventions included: Bilateral half side rails with padding while in bed for safety. Record review of Resident # 56's Physician's Order Sheet for May 2025 revealed an order dated 04/20/2025 for bilateral grab bar with padding for safety related to diagnosis Seizures every shift and monitor for placement/safety. Resident # 106: On 05/06/25 at 12:52 PM Resident#106 was observed in bed with bilateral 1/4 side rails in the upward position; the right-side rail padding was observed on the floor. (photographic evidence). On 05/06/25 at 1:53 PM, Staff E, RN picked up the padding and placed it in the laundry and another staff member replaced the padding on side rail. On 05/06/25 at 1:02 PM Staff E, RN stated: The order is for padding to be on the side rails all the time while the resident is in bed. I do frequent rounds to make sure the padding is in place. I don't know why it was on the floor. On 05/06/25 at 1:12 PM, Staff D, CNA stated, I am the CNA for [Resident # 106]' the padding is to always be on the side rails for safety. I round to make sure. Record review of Resident#106's demographic face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that include Palliative care, Hemiplegia and Hemiparesis following Cerebral infarction affecting left dominant side. Record review of a Quarterly MDS referenced dated 04/09/2025 revealed Resident#106 is severely impaired cognitively and was dependent for transfers. Record review of Resident#106's Physician Orders Sheet for May 2025 revealed an order dated 11/19/24 for bilateral grab bar with padding to help protect skin integrity while in bed every shift for bed mobility/enabler; Monitor for placement/safety. Record review of a care plan revealed Resident#106 had a risk for falls related to poor safety awareness and diagnosis included: Encounter for Palliative Care, Sequelae of Cerebral infarction, Hemiplegia and Hemiparesis, date Initiated: 12/01/2022 and Revision on: 01/10/2025 with a goal to minimize risk of falls and fall related injury through the next review date. The interventions included: Bilateral half side rails while in bed with padding On 05/08/25 at 12:10 PM, the Restorative RN stated: When I receive an order from the physician for padding of the side rails, I provide the staff with the padding, and I round with the restorative CNAs to monitor padding is put in place. The padding is usually for seizure precautions and protection of skin. The floor nursing staff are responsible for ensuring the paddings are in place. There is no time that the padding should not be on the side rails while the resident is in bed. When staff are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few providing care, they remove the padding and put the side rail in the down position but must remain next to the resident for safety. On 05/08/25 at 12:21 PM The Director of Nursing (DON) revealed: Staff are expected to do frequent rounds to ensure the padding remains on the side rails according to the physician order. The restorative, floor nurse and the computer tasks inform the CNAs which residents require padded side rails. The padded side rails are typically used for seizure precaution and skin integrity. There is no reason the padding should not be in place without staff present. Record review of a Policy titled, Comprehensive Care Plan date implemented 3/2020, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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, interview and record review, the facility failed to 1) store food under sanitary condition as evidence by failure in ensuring the 1 North Station Pantry snack/nourishment freezer on the resident unit contained a thermometer on the inside and 2) failed to ensure the correct wash temperature for washing of the dishes and utensils by not having the correct wash temperature for the operable wash tank temperature gauge on the high temperature dish machine. The missing thermometer has the potential to affect 176 out of 185 residents who eat orally residing in the facility at the time of the survey and potential to affect 42 out of 44 residents who eat orally residing on the 1 North Wing. The incorrect/improper wash temperature for the operable dish machine has the potential to affect 176 out of 185 residents who eat orally residing in the facility at the time of the survey. The findings included: 1) Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (revision date February 2024); Policy Statement-The temperature of the refrigerators and freezers will be recorded twice a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Services or supervisor immediately. Temperatures will be recorded on a log; Procedure: 1) Refrigerators and Freezers, c) Freezers shall be at or below 0 degrees Fahrenheit (F) and d) Any temperatures recorded outside these ranges will be reported to the supervisor immediately and maintenance will be notified. Observation of the 1 North Station Pantry snack/nourishment freezer on 5/07/25 at 8:30 AM revealed the freezer did not contain a thermometer and was noted empty with condensation. Photographic evidence submitted. Record review of the Resident Refrigerator/Freezer Temperature Log dated May 7, 2025 documented the freezer temperature was -10 degrees F. Photographic evidence submitted. Observation and interview with Staff A, Registered Nurse 1 North Supervisor on 5/07/25 at 8:34 AM. She confirmed there was no thermometer in the 1 North Pantry freezer used for residents and there should have been one there. Record review of the Resident Refrigerator/Freezer Temperature Log dated May 7, 2025 documented the freezer temperature was -10 degrees F. She confirmed how was the temperature taken in the freezer on May 7, 2025, if there is no thermometer in the freezer. 2) Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (revision date February 2024); Policy Statement-The temperature of the refrigerators and freezers will be recorded twice a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Services or supervisor immediately. Temperatures will be recorded on a log; Procedure: 2) Dishwasher, a) While the dishwasher is running, with a rack going through it, the temperature of the wash tank and rinse tank will be recorded. Temperatures will be recorded for each meal, b) The Wash tank should be 140-160 degrees Fahrenheit (F), or as specified by the manufacturer and d) Any temperatures recorded outside the acceptable levels shall be reported to the supervisor immediately. Maintenance will be notified. Review of the Dish Machine Temperature Log Policy and Procedure (no written date noted); Purpose-To ensure that dishware and utensils are sanitized effectively, the facility will monitor and document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 dish machine temperatures at every meal service in accordance with state and federal sanitation guidelines; Policy: Food and Nutrition Services staff will monitor and document the dish machine's wash and final rinse temperatures for each meal. Any discrepancies or equipment malfunctions will be addressed immediately to maintain sanitation compliance; Procedure: 2) At each meal service, dishwashing staff will: Observe and document the wash temperature, which must reach a minimum of 150 degrees F. Residents Affected - Some Review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F. Observation of the high temperature dish machine on 5/07/25 at 10:04 AM with Staff B, Dietary Aide and the Training Center Account Manager revealed wash dial was at 110 degrees F and the final rinse dial was at 180 degrees F. Staff B, Dietary Aide revealed the wash temperature should be at 160 degree F and that she couldn't see the wash dial to read it. Staff B, Dietary Aide continued to place several more trays with dishes to be washed through the dish machine and the wash dial did not move, it stayed at 110 degrees F and the final rinse dial was at 180 degrees F. Several more cycles were conducted and the wash dial stayed at 110 degrees F and the final rinse dial was at 180 degrees F. The Training Center Account Manager revealed the wash temperature should be 150-160 degrees F. The Training Center Account Manager stopped the dish machine and called the service tech company to come to the facility and service the dish machine. She instructed the dietary staff to use disposable wear for feeding. Photographic evidence submitted. Review of the Dish Machine Log documented for the month of May 7, 2025 documented the wash temperature was 160 degrees F and the final rinse was 180 degrees F for breakfast. Photographic evidence submitted. Observation and interview on 5/07/25 at 12:17 PM, with the dish machine technician. He was observed servicing the dish machine. He stated, The thermostat was low on the wash tank. That is why it was at 110 degrees F. The temperatures should be 160 degrees F. I reset the temperature. Review of the Dish machine Repair Company Correspondence dated 5/08/25 documented the following: Dish machine was checked and tested. Temperature on wash tank was low. Thermostat needed to be reset. Reason: Electrical activity in building. Wash tank temperature-165 degrees F. Temperature reset. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observations, records reviewed and interviews, the facility failed to demonstrate effective plans of actions implemented to correct identified quality deficiencies in problem areas, as evidenced by repeated deficient practices for F 641- Accuracy of Assessments, F812 Food Procurement Store/Prepare/Serve/Sanitary and F867- Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA). These repeated deficient practices have the potential to affect all residents residing in the facility. The findings included: Review of the facility's survey history revealed during a recertification survey with exit dated 12/14/2023,

F812 was cited-Food Procurement Store/Prepare/Serve/Sanitary; due to the facility's failure to store food under sanitary conditions related improper temperatures in the reach-in cooler and failure to ensure the reach-in cooler was working properly; 2)The facility was Cited F641-Accuracy of Assessments related to the facility's failure to accurately code the Minimum Data Set (MDS) and 3) F867 Quality Assurance and Performance Improvement due to the committee's failure in identifying and preventing potential problems and implementation of QAPI/QAA activities. During this survey with exit dated 05/08/2025 the facility was cited F641-Accuracy of Assessments related to the facility's failure to accurately code the Minimum Data Set (MDS); F812-Food Procurement Store/Prepare/Serve/Sanitary; due to the facility's failure to store food under sanitary conditions related to no thermometer observed inside the One North Station Pantry snack/nourishment freezer on the residents' unit, failed to ensure the proper temperature level for washing the dishes and utensils on the operable high temperature dish machine's tank temperature gauge and F867 Quality Assurance and Performance Improvement due to the committee's failure in identifying and preventing potential problems and implementation of QAPI/QAA activities. Record view of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Policy and Procedure issued 6/10/2021, the policy documented: Policy: It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2) c. Develop and implement appropriate plans of action to correct identified quality deficiencies. On 05/08/25 at 04:41 PM, during the QAPI/QAA review with the facility's Administrator and the [NAME] President of Clinical Services, it was revealed the QAPI/QAA meetings are conducted on the last Thursday of each month. The committee members include the Administrator, Director of Nursing, Assistant Director of Nursing, Pharmacy Representative Department Heads. The identified problem areas related to

F641-Accuracy of Assessment, F812-Food Procurement Store/Prepare/Serve/Sanitary in areas and F867 Quality Assurance and Performance Improvement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review the facility failed to ensure the high temperature dish machine wash cycle was working properly. This has the potential to affect 176 out of 185 residents who eat orally residing in the facility at the time of the survey. Residents Affected - Some The findings included: Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (revision date February 2024); Policy Statement-The temperature of the refrigerators and freezers will be recorded twice a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Services or supervisor immediately. Temperatures will be recorded on a log; Procedure: 2) Dishwasher, a) While the dishwasher is running, with a rack going through it, the temperature of the wash tank and rinse tank will be recorded. Temperatures will be recorded for each meal, b) The Wash tank should be 140-160 degrees Fahrenheit (F), or as specified by the manufacturer and d) Any temperatures recorded outside the acceptable levels shall be reported to the supervisor immediately. Maintenance will be notified. Review of the Dish Machine Temperature Log Policy and Procedure (no written date noted); Purpose-To ensure that dishware and utensils are sanitized effectively, the facility will monitor and document dish machine temperatures at every meal service in accordance with state and federal sanitation guidelines; Policy: Food and Nutrition Services staff will monitor and document the dish machine's wash and final rinse temperatures for each meal. Any discrepancies or equipment malfunctions will be addressed immediately to maintain sanitation compliance; Procedure: 2) At each meal service, dishwashing staff will: Observe and document the wash temperature, which must reach a minimum of 150 degrees F. Review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F. Observation of the high temperature dish machine on 5/07/25 at 10:04 AM with Staff B, Dietary Aide and the Training Center Account Manager revealed wash dial was at 110 degrees F and the final rinse dial was at 180 degrees F. Staff B, Dietary Aide revealed the wash temperature should be at 160 degree F and that she couldn't see the wash dial to read it. Staff B, Dietary Aide continued to place several more trays with dishes to be washed through the dish machine and the wash dial did not move, it stayed at 110 degrees F and the final rinse dial was at 180 degrees F. Several more cycles were conducted and the wash dial stayed at 110 degrees F and the final rinse dial was at 180 degrees F. The Training Center Account Manager revealed the wash temperature should be 150-160 degrees F. The Training Center Account Manager stopped the dish machine and called the service tech company to come to the facility and service the dish machine. She instructed the dietary staff to use disposable wear for feeding. Photographic evidence submitted. Review of the Dish Machine Log documented for the month of May 7, 2025 documented the wash temperature was 160 degrees F and the final rinse was 180 degrees F for breakfast. Photographic evidence submitted. Observation and interview on 5/07/25 at 12:17 PM, with the dish machine technician. He was observed servicing the dish machine. He stated, The thermostat was low on the wash tank. That is why it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 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 106128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 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 0908 at 110 degrees F. The temperatures should be 160 degrees F. I reset the temperature. Level of Harm - Minimal harm or potential for actual harm Review of the Dish machine Repair Company Correspondence dated 5/08/25 documented the following: Dish machine was checked and tested. Temperature on wash tank was low. Thermostat needed to be reset. Reason: Electrical activity in building. Wash tank temperature-165 degrees F. Temperature reset. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106128 If continuation sheet Page 12 of 12