Health inspection·March 24, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure for Advance Directives dated 3/1/2021 was completed. The Policy Intent: It is the policy of the facility to honor Advance Directives in accordance to State and Federal Regulations. Procedure: 1. The facility will have written policies and procedures which delineate the nursing home's position with respect to the state law and rules relative to advance directives. 2. The policies must not condition treatment or admission upon whether or not the individual has executed or waived an advance directive. In the event of conflict between the facility's policies and procedures and the individuals advance directive, provision should be made in accordance with Section 765.1105, F.S. 3. The facility's policy must include: Providing each adult individual at the time of admission as a resident, with a copy of Health Care Advance Directives-The Patients Right to Decide . 4. The facility will provide each adult individual, at the time of admission as a resident, with written information concerning the nursing home's policies respecting advance directives; and provide documentation of the existence of an advance directive within the medical record. 5. The facility will place a copy of the individuals advance directive a part of the individuals medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 2 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 2) Observation of Resident # 51 on 3/20/2023 at 9:00 AM revealed the resident sitting in a wheelchair in his room. Observation of the resident's room revealed the toilet in disrepair. The water in the toilet was running and the sound was loud. (Photographic evidence submitted) Observation and interview with the Maintenance Director on 3/24/2023 at 8:14 AM. He confirmed the toilet water was running and not in good repair. He revealed he would work on it and fix it. 3) Observation of Resident # 91 on 3/21/23 at 9:15 AM revealed the resident lying in bed, wearing glasses. Observation of the resident's room revealed a long line and a crack in the ceiling with a brown, rust like water spot on the ceiling. (Photographic evidence submitted) Observation and interview with the Maintenance Director on 3/24/23 at 8:06 AM. He stated, The reason for the rust like brown spot is because the building had a leaking pipe on Sunday night and it was fixed Monday morning. Now, it is dry and we primed it and it will be used to compounded and painted. We started working on it first thing this morning, when the Life Safety surveyor, pointed it out to us on yesterday. Based on observations and interviews and records reviewed the facility failed to provide a safe, clean, comfortable, and homelike environment, as evidenced by strong urine odor noted throughout the facility. 2) unclean, disrepair unkempt environment to include disrepair toilet in Resident # 51) unclean ceiling in resident room (Resident # 91). This deficient practice has the potential to affect all residents residing in the facility at the time of this survey. The findings included: 1) On 3/20/23 at 6:00 AM, upon entrance into the facility and during tour of the facility a strong urine ordor was noted. During the tour on Wing A and Wing B of the facility on 03/20/2023 at 06:00 AM, a strong urine odor. During the observational tour of Wing D and E on 03/20/2023 at 06:15 AM, there was a strong urine odor noted. On 03/20/2023 at 06:37 AM a strong urine odor was noted on Wing G during the observational tour. On 03/21/2023 at 07:30 AM there continued to be a strong urine odor noted on Wing D. On 03/21/2023 at 08:00 AM there was a strong urine odor on Wing G. On 03/23/2023 at 07:44 AM there was a strong urine odor noted on Wing D and E. On 03/23/2023 at 08:05 AM, there was a strong urine odor on Wing G. On 03/24/2023 at 10:38 AM, a strong urine odor was noted on Wing B. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 3 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 24/2023 at 10:45 AM, a strong urine odor was noted on the Wing G. The surveyor knocked on Resident # 146's door and the resident responded yes and the surveyor entered the room. Upon entering the room the floor was noted to be covered in urine and Resident # 146 was standing by the bed urinating on the floor. The nurse was notified and she called the housekeeping immediately. During an interview with the Housekeeping Director on 03/24/2023 at 08:41 AM. The Housekeeping Director revealed that sometimes when the staff were changing the residents the facility smelled like that, but there is nothing they can do. She stated they are not allowed to spray any chemicals, because it is not healthy for the residents. She stated they use a chemical in the water to prevent the smell and they cleaned the resident's room as soon as the nursing staff finished changing the residents. In an interview on 03/24/2023 the facility's Administrator stated for the the smell in the facility she will investigate what chemicals are being used by Housekeeping Department. Review of the facility's Policies and Procedures for Physical Environment Section Housekeeping and Maintenance issued 03/2020 revealed Policy: It is the policy of the facility to provide a safe environment in accordance with State and Federal Regulations. Procedure: 5) The facility will provide a safe, functional, sanitary, and comfortable environment for residents, 9) The facility will provide a. housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 4 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to respond to grievances for one (Resident #120) out of one resident reviewed for grievances. The resident's brother established communication with the facility concerning complaints about the brother's care with rehabilitation and was not informed of the results of the grievance. There were 207 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Grievance (written 3/01/2022) documented the following: Intent: It is the policy of the facility to have a grievance process in accordance to State and Federal regulations; Procedure: 1) The facility will have a grievance procedure available to its residents and their families. The grievance procedure must include: a) An explanation of how to pursue redress of a grievance, e) Each nursing home facility shall maintain records of all grievances and a report, subject to agency inspection, of the total number of grievances handled, a categorization of the cases underlying the grievances and the final disposition of the grievances and f) Each facility must respond to the grievance within a reasonable time after its submission. Observation of Resident #120 on 3/20/2023 at 9:50 AM revealed the resident lying in bed, watching TV. Interview with Resident #120's brother via telephone on 3/21/2023 at 2:15 PM revealed that he spoke with someone in the facility last week about his brother receiving physical and speech therapy to make him stronger. He revealed that no one had gotten back with him yet about it and if his brother would be receiving physical and speech therapy. Review of the Demographic Face Sheet for Resident #120 documented the resident was admitted on [DATE] with a diagnoses to include metabolic encephalopathy, cerebral infarction, speech and language deficits, psychosis, hypertension and anxiety disorder. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #120 dated 3/08/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 09 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and received SLP (Speech Language Pathology) Therapy Start Date-6/02/2022, Therapy End Date-6/16/2022; OT (Occupational Therapy): Therapy Start Date-6/02/2022, Therapy End Date-8/18/2022 and PT (Physical Therapy): Therapy Start Date-6/02/2022, Therapy End Date-8/17/2022. Review of the grievance log for Resident #120 dated December 2021-March 2023 revealed there were no grievances noted for the resident. Review of the Social Services Progress Notes for Resident #120 dated 3/13/2023 at 15:56:00 documented the resident's brother, inquire to have more therapy. Therapy was made aware. Interview with the Social Services Director on 3/24/2023 at 10:10 AM. She stated, I wrote the social services note on 3/13/23 for therapy. I let therapy know and did not write a grievance. I did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 5 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0585 follow up with therapy to see what they did and the brother was not notified. Level of Harm - Minimal harm or potential for actual harm Review of the PT/OT Screen Referral for Resident #120 dated 3/13/2023 documented the following: Diagnosis: Unsteady gait; Family request; Resident has maintain PLOF (prior level of function), no change in condition noted. Therapy not indicated at this time. Residents Affected - Few Interview with the Director of Rehabilitation on 3/24/2023 at 11:01 AM. She stated, He is not currently on caseload. He received PT and OT services on 6/01/2022 to 8/18/2022 and SLP services on 6/02/2022 to 6/16/2022. I've screened him quarterly and he is still at the same function. He has had no decline or improvement and continues to remain at previous level of function. A screening was done on 3/13/2023 and he is not eligible for therapy at this time. We discuss the resident in the clinical meeting every morning. I don't know if the resident's brother was notified of his brother's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 6 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a notice to the Ombudsman concerning a discharge to the hospital for one (Residet #211) out of three residents reviewed for hospitalization. The findings included: Record review of the facility's policy titled, Transfer and Discharge Requirements (written [DATE]) documented the following: Policy: It is the policy of the facility to transfer and discharge the resident according to State and Federal regulations; Procedure: 2) When the facility transfers or discharges a resident, the resident's clinical record will include documentation related to the reason for the discharge or transfer, 4) When a discharge or transfer is initiated by the nursing home, the nursing home administrator employed by the nursing home that is discharging or transferring the resident or an individual employed by the nursing home who is designated by the nursing home administrator to act on behalf of the administration, must sign the notice of discharge or transfer, 11) The notice must be in writing and must contain all information required by state and federal law, rules or regulations. Such document must include a means for a resident to request the local long-term care ombudsman council to review the notice and request information about or assistance with initiating a fair hearing with the department's Office of Appeals Hearings. A copy of the notice must be placed in the resident's clinical record and a copy must be transmitted to the resident's legal guardian or representative and to the local ombudsman council within 5 business days after signature by the resident or resident designee. Closed record review of the Demographic Face Sheet for Resident #211 documented the resident was admitted on [DATE] with a diagnosis of end stage renal disease, diabetes mellitus, chronic obstructive pulmonary disease, respiratory failure, dependence on renal dialysis, heart failure, hypertension, schizophrenia and anxiety disorder. The resident was discharged to the hospital on [DATE]. The resident was readmitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] for Resident # 211 documented the resident's Mental Status (BIMS) Summary Score was 15 out of 15, indicating no cognitive impairment, able to make own decisions, required extensive assistance with one person physical assist for ADLs (activities of daily living) and received oxygen therapy and dialysis services. Review of the Physician's Order Sheets (POS) for Resident # 211 dated [DATE], February 2023 documented the resident received insulin for diabetes mellitus, Buspirone HCL for anxiety disorder, inhalation aerosol for chronic obstructive pulmonary disease, Olanzapine for schizophrenia, Lorazepam for anxiety disorder and insomnia, oxygen for shortness of breath and received in-house dialysis services. Review of the Medication Administration Record (MAR) for Resident # 211 dated [DATE], February 2023 documented the resident received medications as ordered by the medical doctor. Review of the care plans for Resident # 211 (written [DATE]; reviewed & updated) documented the resident had care plans for ADLs, ESRD (end stage renal disease), diabetes mellitus, hypertension, cardiovascular, psychotropic meds, falls, skin integrity, oxygen, nutrition and hydration. The goals and interventions were appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 7 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Progress Notes for Resident # 211 documented the following: Dated [DATE] at 15:00-Narrative Note: Late Entry-Resident received from dialysis unresponsive. Vital signs taken. MD was at the facility at that time, order received to call 911. Awake for the rescue to arrive. Resident transfer to [local hospital] for further evaluation; Dated [DATE] at 6:40 AM-Narrative Note: Late Entry-Resident noted with breathing difficulties with a respiratory rate of 22 with O2 nasal cannula in place. Prompt intervention in administering breathing treatment to alleviate breathing difficulties that benefit resident only for short period of time and resident is observed in and out of consciousness. Vital signs taken 911 was called for rescue; noted that resident status is deteriorating from difficulty breathing to cardiac arrest. In process, CPR initiated. Call placed to attending physician who gave order to transfer resident to hospital. Review of the Ombudsman Form for Resident # 211 dated [DATE] and [DATE] documented the discharge and transfer form was completed but it was not documented when the form was sent to the Ombudsman. Interview with the Social Services Director on [DATE] at 10:04 AM. She stated, We send them every Friday to the Ombudsman. The February form was not sent to the Ombudsman. The form was found in the nurses' station. The January form was sent to the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 8 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a bed hold policy to the resident concerning a discharge to the hospital for three (Resident # 211, Resident #175 and Resident # 62) out of three residents reviewed for hospitalization. The findings included: 1) Record review of the facility's policy titled, Bed Hold Notice Upon Transfer (written 11/2019) documented the following: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed; Policy Explanation and Compliance Guidelines: 1) Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility, 5) The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. Closed record review of the Demographic Face Sheet for Resident #211 documented the resident was admitted on [DATE] with a diagnosis of end stage renal disease, diabetes mellitus, chronic obstructive pulmonary disease, respiratory failure, dependence on renal dialysis, heart failure, hypertension, schizophrenia and anxiety disorder. The resident was discharged to the hospital on [DATE]. The resident was readmitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] for Resident # 211 documented the resident's Mental Status (BIMS) Summary Score was 15 out of 15, indicating no cognitive impairment, able to make own decisions, required extensive assistance with one person physical assist for ADLs (activities of daily living) and received oxygen therapy and dialysis services. Review of the Physician's Order Sheets (POS) for Resident # 211 dated [DATE], February 2023 documented the resident received insulin for diabetes mellitus, Buspirone HCL for anxiety disorder, inhalation aerosol for chronic obstructive pulmonary disease, Olanzapine for schizophrenia, Lorazepam for anxiety disorder and insomnia, oxygen for shortness of breath and received in-house dialysis services. Review of the Medication Administration Record (MAR) for Resident # 211 dated [DATE], February 2023 documented the resident received medications as ordered by the medical doctor. Review of the care plans for Resident #211 (written [DATE]; reviewed & updated) documented the resident had care plans for ADLs, ESRD (end stage renal disease), diabetes mellitus, hypertension, cardiovascular, psychotropic meds, falls, skin integrity, oxygen, nutrition and hydration. The goals and interventions were appropriate. Review of the Progress Notes for Resident # 211 documented the following: Dated [DATE] at 15:00-Narrative Note: Late Entry-Resident received from dialysis unresponsive. Vital signs taken. MD was at the facility at that time, order received to call 911. Awake for the rescue to arrive. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 9 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transfer to [local hospital] for further evaluation, Dated [DATE] 06:40-Narrative Note: Late Entry-Resident noted with breathing difficulties with a respiratory rate of 22 with O2 nasal cannula in place. Prompt intervention in administering breathing treatment to alleviate breathing difficulties that benefit resident only for short period of time and resident is observed in and out of consciousness. Vital signs taken 911 was called for rescue; noted that resident status is deteriorating from difficulty breathing to cardiac arrest. In process, CPR initiated. Call placed to attending physician who gave order to transfer resident to hospital. Review of the Bed Hold Policy Form for Resident # 211 revealed there were no bed hold policies documented in the resident's chart for hospital transfers dated [DATE] and [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 2:56 PM. She stated, When a resident is transferred out to the hospital they are supposed to receive a bed hold policy. On [DATE], the resident was received from dialysis unresponsive. Vital signs were taken. The MD (medical doctor) was at the facility at that time, order received to call 911. He was awake for the rescue to arrive. The resident was transfer to the hospital for further evaluation. On [DATE], the resident was noted with breathing difficulties with a respiratory rate of 22 with oxygen nasal cannula in place. Vital signs were taken, 911 was called for rescue; noted that resident status is deteriorating from difficulty breathing to cardiac arrest. In process, CPR initiated. Call placed to attending physician who gave order to transfer resident to hospital. 2) Review of the medical records for Resident #62 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Encounter for Palliative Care, Acute Respiratory Distress, Do Not Resuscitate (DNR) and Hospice. Resident #62 was discharged to the hospital on [DATE] for altered mental status and readmitted on [DATE]. Further Review of Resident #62's medical records revealed: Resident #62's Bed hold policy for Discharge Return Anticipated on [DATE] was not completed. Review of the Physician's Orders Sheet for [DATE] revealed Resident #62 had orders that included but not limited to: Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML-Give 0.5 ML sublingually every 2 hours as needed for SOB. Record review of Resident # 62's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section B for Hearing and vision documented adequate hearing and vision and clear speech. Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS)- 12 on a 0-15 scale indicating the resident is cognitively moderately impaired. Section E for behaviors documented no behaviors exhibited. Section G for Functional Status Documented-Bed mobility-extensive assistance, Transfer-Total Dependence, Toilet use, personal hygiene, and Eating-supervision. One person's assistance required. Section J for Health Conditions documented No falls, received no scheduled or as needed pain medications in the last 5 days. Section N for Medications documented resident received insulin, antipsychotic, antidepressants, and diuretics in the last 7 days. Section O for special Programs, Procedures and Treatments documented resident received Occupational therapy and Hospice care in the last 14 days. Review of the discharge summary progress note for Resident # 62 dated [DATE] timestamped 14:40 late entry documented: Chest X- Ray result received, and Nurse Practitioner made aware, order received to send resident out via 911 related to pulmonary edema diagnosis. Resident transferred hospital; responsible party made aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 10 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 04:25 PM the Social Services Director stated that when a resident goes to the hospital the nurse fills out the paperwork, it is then given to medical records, social services then fax the ombudsman letter to their office once a week, usually on Fridays. Regarding the bed hold policy, the Social Services Director stated: I will find out who takes care of that and let you know. On [DATE] at 04:54 PM the Social Services Director presented the discharge transfer notification to Ombudsman for Resident # 62 and stated the facility does not do bed hold policies because the facility is not up to 95% capacity. 3) During an observation on [DATE] at 07:55 AM Resident #175 was observed in bed. The head of bed elevated and tube feeding running at 50 milliliters per hour (ml/hr.) and flush at 50 ml/hr. and oxygen in place via nasal cannula at 2 liters per minute. Review of the medical records for Resident #175 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Osteomyelitis, unspecified. Resident #175 was discharged to the hospital on [DATE] for altered mental status and readmitted on [DATE]. Further Review of Resident #175's medical records revealed the bed hold policy for the discharge return anticipated on [DATE] was not completed. Review of Resident #175 's admission Minimum Data Set (MDS) dated [DATE] revealed: . Section B for Hearing and vision documented adequate hearing and vision and unclear speech Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is unable to be determined. Section G For Functional Status documented resident is total dependence for Activities of Daily Living (ADLS) with one person assistance. Section J for Health Conditions documented No falls, no shortness of breath. Section N for Medications documented resident received insulin, anticoagulants, antibiotics, and diuretics in the last 7 days. Section O for Special Programs, Procedures and Treatments documented resident received oxygen in the last 14 days. Interview on [DATE] at 04:25 PM, the Social Services Director stated when a resident goes to the hospital the nurse fills out the paperwork, it is then given to medical records, social services then fax the ombudsman letter to their office once a week, usually on Fridays. Regarding the bed hold policy; I will find out who takes care of that and let you know. On [DATE] at 04:54 PM, the Social Services Director presented the discharge transfer notification to Ombudsman for Resident # 175 and stated the facility does not do bed hold policies because the facility is not up to 95% capacity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 11 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 document an accurate Minimum Data Set (MDS) related to oxygen use for one (1) out of 61 residents receiving respiratory treatment (Resident #134). Residents Affected - Few The finding included: Observation on 03/21/2023 at 07:29 AM revealed, Resident #134 in bed asleep, the resident had tube feeding Nepro with Carbohydrates, 45 cc(cubic centimeters) per hour, a water flush 40 cc/hr. The resident was receiving oxygen at 1 1/2 liters per minute via nasal cannula, with a humidifier bottle dated 3/12, the bag on oxygen canister was dated 3/12. Observation of Resident #134 on 03/24/23 at 02:00 PM, revealed the resident was receiving oxygen at 1 1/2 liters via nasal cannula. During the review of Resident #134's clinical records it was noted that the resident had a physician order for oxygen at 2 liters via nasal cannula continuous. Review of Residents #134's care plan indicated the resident is at risk for ineffective breathing pattern related to: Pulmonary Edema and Respiratory Failure. With a goal of [ ] will demonstrate an effective respiratory rate, depth and pattern, increase activity tolerance and no stated discomfort thru NRD (next review date). Adjust head of bed and body positioning to assist ease of breathing. Administer medication/oxygen as ordered. Arrange activities to allow adequate rest and increase activities as tolerated. Instruct resident in relaxation techniques. Keep HOB elevated to facilitate easy respirations. Monitor lab reports and refer to MD. Monitor lung sounds, pallor, cough and character of sputum. Monitor resident's anxiety and give support/assistance as needed. Monitor respiratory rate, depth and effort. On 03/24/23 at 02:12 PM, Staff G, a Licensed Practical Nurse and Unit Manager for the [NAME] unit was asked to check the oxygen order for Resident #134, she checked the electronic medical record and reported the oxygen was ordered for 2 liters per minute. Staff G was was asked to check the resident's oxygen concentrator. Staff G acknowledged the oxygen was set at 1 1/2 liters per minute and increased the oxygen to 2 liters. Review of Resident #134's Quarterly Minimum Data Set (MDS) assessment reference dated 3/5/2023, did not document the use of oxygen in section O100. Resident # 134's admission MDS with assessment reference dated 12/3/2022 documented in section O100 - oxygen was in use. During an interview on 03/24/2023 at 01:13 PM with Staff S, Registered Nurse (RN), MDS coordinator. Staff S was asked whether, the MDS Quarterly dated 3/5/2023 should be marked for oxygen in section O100-C-Oxygen. Staff S reported, yes. The facility's staff did not document the use of oxygen on the Quarterly MDS assessment reference date 3/5/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 12 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for serious mental illness (SMI) or intellectual disability (ID) was completed at the time of admission for one resident (Resident #40) and failed to request Level II PASRR for eight residents (Resident # 40, Resident #63, Resident # 28, Resident # 34, Resident #146, Resident #118 and Resident #120 and Resident #53) out of twelve residents whose PASRR were reviewed. This deficient practice had the potential to affect 207 residents residing in the facility at the time of the survey. Residents Affected - Some The findings included: 1) Observation of Resident #40 on 03/24/2023 at 11:32 AM; revealed the resident lying on his bed, watching television. No distress or anxiety was noted. Resident stated he was doing well. Review of the clinical records for Resident # 40 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but not limited to, Essential (Primary) Hypertension; Major Depressive Disorder, Recurrent, Unspecified; Unspecified Psychosis Not Due to a Substance or Known Physiological Condition; Type 2 Diabetes Mellitus without Complications. Record review of Level I Preadmission Screening of Resident Review (PASRR) dated 03/07/2023 Section I Screen Decision Making Section A was not marked as the resident had diagnosis of serious mental illness. Section IV PASRR Screen Completion stated the resident had no mental illness or suspicion. The form revealed the resident was not a provisional admission. Record review of physician's orders dated 03/14/2021 revealed the resident was receiving Fluoxetine HCL capsule 10 milligrams, 1 capsule by mouth one time a day for Major Depressive Disorder, Recurrent, Unspecified. Review of the Medication Administration Record for March 2023 revealed the resident received Fluoxetine HCL capsule of 10 milligrams as ordered. Review of Annual Minimum Data Set (MDS) Section C for Cognitive Pattern dated 01/21/2023 revealed the resident's Brief Interview for Mental Status (BIMS) summary score was 12 of 15 indicating the resident has moderately impaired cognition. Review of Annual MDS Section I Active Diagnosis dated 01/21/2023 revealed the resident's diagnosis were depression and psychotic disorder. Review of Annual MDS Section N for Medications dated 01/21/2023 revealed the resident was receiving antidepressant medication seven days in a week. Antipsychotic medication was discontinued on 01/15/2023. Review of Resident # 40's Care Plan initiated on 01/09/2020 and the next review date 04/26/2023 revealed the resident was at risk for adverse medications effects secondary to the use of: Antipsychotic and antidepressants. Goal: Risk for complications related to psychosis medications will be minimized daily through the next review date. Interventions: Administer medications as prescribed. Dose reduction at least twice per year if indicated. Monitored resident for adverse effects of medication such as: dizziness, drowsiness, insomnia, sedation, weakness, unsteadiness, depression, headache, hypotension, abdominal discomfort, decreased appetite and report to physician. Observed and monitored for adverse reactions to medications. Psychiatrist consultation as needed. During an interview with Resident # 40 on 03/24/2023 at 10:50 AM. Resident # 40 stated he was feeling well, but had pain in his back and the nurse gave medication for it, and he was feeling better (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 13 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 now. Resident # 40 stated that he likes to stay in his room watching television. Level of Harm - Minimal harm or potential for actual harm Interview with Staff D, a Licensed Practical Nurse (LPN) on 03/24/2023 at 11:23 AM. She stated the resident was quiet, not aggressive, very cooperative with the staff when care is provided, he had no behaviors, tolerated the medication very well and she monitored the resident's mood and behavior before administering the medications. Residents Affected - Some 2) Observation of Resident # 63 on 03/23/2023 at 8:03 AM; revealed the resident was sitting in his bed having breakfast. Observation of Resident # 63 on 03/24/2023 at 09:05 AM; revealed the resident was seated on his bed watching television. Review of Resident #63's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included, but were not limited to, Major Depressive Disorder, Recurrent, Unspecified; Other Schizophrenia; Cardiac Arrhythmia, Unspecified; Insomnia, Unspecified. Review of PASRR Level I dated 03/14/2023 revealed identification of a mental diagnosis under 1A. Section 1B was checked for Serious Mental Illness. Section 4 revealed the individual had no diagnosis or suspicion of serious mental illness (SMI) or intellectual disability (ID) indicated. Level II PASRR evaluation not required. Review of physician orders dated 06/25/2021 revealed the resident was receiving Remeron (Mirtazapine) tablet 15 milligrams; 1 tablet by mouth at bedtime related to Insomnia, Unspecified. Review of Medication Administration Records for March 2023 revealed the resident was receiving Remeron tablet 15 milligrams as ordered. Record review of Resident #63's Care Plan initiated on 08/30/2016 and the next review date 04/03/2023 revealed the resident was at risk for mood and behavior related to taking items off the dirty tray. 11/01/2022 Resident is an attention seeker and perseverative thinker. Resident stating that he was being followed by the government and was concerned that the government was intercepting his packages. Goal: the resident will have a stable mood and behavior and no demonstrations of problem behavior observed or documented through the next review date. Interventions: Administer medications as ordered and monitor for adverse side effects, reported to physician as indicated. Asked the resident what is causing behavior and attempt to resolve issue where possible. Continue to approach in a calm reassured manner. Always maintain a pleasant mood/tone of voice. Coordinated care with family as needed. Follow up psychiatrist consult as ordered or needed. Give space when resident is agitated or restless. Monitor mood, behavior, and document as needed. Provide a safe environment. Reoriented /redirected calmly. Record review of Resident #63's Care Plan initiated on 08/13/2016 and the next review date 04/03/2023 the resident was noted with diagnosis of Schizophrenia and Depression and currently taking antidepressant medication for depression. Goal: Resident's mood will be managed with current medication regime as evidenced by resident continued interaction with staff and will continue to leave room for activities daily through the next review date. Interventions: Assisted resident/family/caregivers to identify strengths, positive coping skills and reinforced these. Encouraged the resident to participate in activities and pursue life within the facility daily through the next review date. Invited the resident to activities and encouraged participation. Monitored/documented to determine if problems (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 14 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some are related to external causes. Psychiatrists consult as ordered or as needed. Spend time talking to the resident, family, encouraged to express feelings. Record review of Resident #63's Medicare 5-days Minimum Data Set (MDS) Section C for Cognitive Patterns dated 03/23/2023 revealed the resident's Brief Interview for Mental Status (BIMS) summary score was 15 of 15 meaning the resident is cognitively intact. Section I for Active Diagnosis dated 03/23/2023 revealed the resident had Depression and Schizophrenia. Section N for Medications dated 03/23/2023 revealed the resident was receiving antidepressant medication. Record review of Behavior Notes dated 02/12/2023 revealed the resident was observed with aggressive behavior toward another resident and was non-complaint with re-direction, yelling at staff. The resident continued to display inappropriate behavior. Teaching provided, however the resident continued to be the same. Call place to physician, no new order at this moment. Will continue to monitor the resident. Record review of Behavior Notes dated 11/28/2022 Around 02:50 PM the housekeeping supervisor went to speak with the resident about the items that had already been returned to him last week, when the resident started yelling at her. The resident stated to the housekeeping supervisor I'm talking shut the hell up. The resident was redirected and then called the police. Call placed to physician; new order received for psych consultation. Interview with Staff E, Licensed Practical Nurse (LPN) on 03/24/2023 at 09:48 AM. Staff E stated the resident was sometimes non-compliant. The resident refused to receive care, refused to take the medications even though she talked to him calmly, he had to be redirected and she would leave and return later, then the resident would take the medications. 3) Observation of Resident #28 on 03/21/2023 at 3:06 PM. Revealed the resident was on modified contact precautions. Resident # 28 reported someone had made him feel afraid, but he did not remember the person, and he had told the Director of Nursing and it was taken care of. On 03/23/2023 at 09:20 AM, Resident #28 was observed sleeping in his bed. No distress or anxiety was noted. Record review of the clinical records for Resident #28 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but were not limited to, Schizophrenia, Unspecified; Anemia Unspecified; Colostomy Status. Record review revealed Resident #28 was transferred to a local hospital on [DATE] due to wound care. Record review of Resident #28's PASRR Level I dated 03/14/2023 revealed identification of a serious mental illness under 1A. Section 1B was checked for Serious Mental Illness. Section 4 revealed the individual had no diagnosis or suspicion of serious mental illness (SMI) or intellectual disability (ID) indicated. Level II PASRR evaluation not required. Record review of Resident #28's physician orders dated 03/19/2023 revealed the resident was receiving Risperdal (Risperidone) Oral tablet 0.5 milligrams; 1 tablet by mouth once a day related to Schizophrenia, Unspecified. Orders dated 03/19/2023 revealed the resident was receiving Seroquel (Quetiapine Fumarate) Oral tablet 25 milligrams. Give 0.5 tablet by mouth once a day related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 15 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Schizophrenia, Unspecified. Orders dated 03/19/2023 revealed the resident was receiving Seroquel (Quetiapine Fumarate) Oral tablet 25 milligrams; 1 tablet by mouth at bedtime related to Schizophrenia, Unspecified. Review of order dated 03/23/2023 revealed the resident was receiving Oxycodone oral tablet 5-325 milligrams Controlled drug. Give 1 tablet by mouth every shift for moderate severe pain (4-10) prior to wound care. Review of the Medication Administration Record for March 2023 revealed the resident was receiving medications as ordered. Record review of Resident #28's Quarterly Minimum Data Set (MDS) Section C for Cognitive Patterns dated 03/08/2023 revealed the resident's Brief Interview for Mental Status (BIMS) summary score was 15 of 15 indicating the resident is cognitively intact. Review of Quarterly MDS Section I for Active Diagnosis dated 03/08/2023 revealed the resident had Schizophrenia. Review of Quarterly MDS Section N for Medications dated 03/08/2023 revealed the resident was not receiving medication. Medications were ordered on 03/19/2023. Record review of Resident #28's Care Plan initiated on 03/09/2023 target completion date 03/13/2023. The resident was at risk for drug related side effects due to the use of psychotropic medications. Diagnosis: Schizophrenia. Goal: The resident will remain free of drug related side effects through the next review date. Interventions: Assessed for fall risk and precautions needed. Encouraged the resident to participate in activities as tolerated. Licensed Nurse to follow up behavior monitoring sheet. Medicated as ordered. Psychiatrist consultation/evaluation as needed. Monitor behavior and mood every shift and documented. Monitor for adverse side effects of drugs (lethargy, dizziness, increased confusion, gait disturbance). Monitored for behavior/mood changes. Notify Social Services Director of any changes in behavior pattern. Observed the resident for decline in function. Physical/Occupational Therapy screen as needed. Reported changes to physician as needed. During an interview with Staff G LPN/Unit Manager on 03/24/23 at 11:00 AM. Staff G reported that Resident #28 was transferred to the hospital yesterday afternoon. The wound care doctor was in the facility and ordered to transfer the resident to the hospital. On 03/24/2023 at 12:50 PM; Staff G stated that Resident # 28 had never reported being afraid of staff. Record review of Resident #28's Behavior Notes revealed a late entry note dated 12/22/2022 that documented: Resident refused medication administration. Teaching provided and encouragement given. Resident was informed on the use of his medications in relation to his diagnosis however he continued to refuse. Call placed to physician, cannot be reach, message left. The resident will continue to be encouraged to comply with care and medication administration as ordered. The resident was alert, awake and oriented to person, place, time, and situation and noted as self- responsible. A call placed to guardianship and one of his contacts listed, cannot be reached message left. Will follow up in the morning. 4) Observation of the Resident #34 on 03/23/23 10:09 AM; revealed the resident was sleeping, naked with his legs hanging off and down the bed. Staff were called to position him, and the resident responded very aggressively to the staff. On 03/24/2023 at 09:20 AM Resident #34 was observed sleeping in his bed and with his legs down the bed. Staff F Registered Nurse (RN) came to have the resident repositioned and resident responded aggressively, and Staff F left the resident alone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 16 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of t Resident #34's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but are not limited to, Paranoid Schizophrenia; Other Seizures; Other Secondary Parkinsonism; Anxiety Disorder, Unspecified; Conduct Disorder, Childhood-Onset Type. Record review of PASRR Level I dated 03/14/2023 revealed identification of a mental diagnosis under 1A. Section 1B was checked for Serious Mental Illness. Section 4 revealed the individual had no diagnosis or suspicion of serious mental illness (SMI) or intellectual disability (ID) indicated. Level II PASRR evaluation not required. Review of orders dated 03/07/2022 revealed the resident was receiving Trazodone HCL tablet 150 milligrams. Give 1 tablet by mouth twice a day for Agitation/Aggressive Behaviors related to Schizophrenia. Monitor behavior, mood, sleep, and appetite. Orders dated 03/07/2022 revealed the resident was receiving Buspirone HCL tablet 15 milligrams, 1 tablet by mouth three times a day for anxiety. Orders dated 03/07/2022 revealed the resident was receiving Depakene Solution 250 milligrams/5 milliliters (Valproate Sodium), 10 milliliters by mouth twice a day related to Paranoid Schizophrenia. Orders dated 06/10/2022 revealed the resident was receiving Quetiapine Fumarate tablet 300 milligrams, 1 tablet by mouth twice a day related to Paranoid Schizophrenia. Orders dated 10/06/2022 revealed the resident was receiving Haloperidol Tablet 10 milligrams. Give 10 milligrams by mouth twice a day related to Paranoid Schizophrenia. Orders dated 10/06/2022 revealed the resident was receiving Haloperidol Decanoate Solution. Inject 150 milligrams intramuscular every 1 month, starting on the 15th for 1 day related to Paranoid Schizophrenia. Review of the Medication Administration Record for March 2023 revealed the resident was receiving medications as ordered. Record review of Resident #34's Care Plan initiated on 01/12/2021 revealed the resident was at risk for drug related side effects due to use of psychotropic medications. Diagnosis: Anxiety, Depression, Schizophrenia, Psychosis. Goal: the resident will remain free of drug related to side effects through next review date. Interventions: Assessed for fall risk and precautions needed. Encouraged the resident to participate in activities as tolerated. License Nurse to follow up behavior monitoring sheet. Medicate the resident as ordered. Psychiatrist consultation/evaluation as needed. Monitor behavior and mood every shift and documented. Monitor for adverse side effects of drugs (lethargy, dizziness, increased confusion, gait disturbance). Monitor ed for behavior/mood changes. Notify Social Services Director of any change in behavior pattern. Observed for decline in function. Physical/Occupational Therapy screen as needed. Report changes to physician as needed. Record review of Annual Minimum Data Set (MDS) Section C for Cognitive Patterns dated 01/15/2023 revealed the Brief Interview for Mental Status (BIMS)summary score was 00 of 15 suggesting the resident has severe cognitive impairment Review of Annual MDS Section I for Health Diagnosis dated 01/15/2023 revealed the resident's diagnosis were Anxiety, Depression and Schizophrenia. Review of Annual MDS Section N for Medications revealed the resident was receiving antipsychotics, antianxiety and antidepressant medications. Record review of Behavior Notes revealed a late entry dated 01/04/2023 indicating: Resident noted lying on the floor, attempted to assist resident back to bed however the resident refused by shaking his head. Teaching and encouragement were provided but the resident refused to get up. Ensured resident was safe and offered a pillow for comfort. The resident refused the pillow. Safety measures in place will continue to do frequent rounds and encourage the resident to lay on his bed. Physician made aware of behavior; order received to continue with frequent rounds. Care plan to be updated to reflect behavior. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 17 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5) Observation of the Resident #146 on 03/23/2023 at 11:05 AM; revealed the resident seated on his bed, drinking water. He did not answer the questions asked. On 03/24/2023 at 10:45 AM; Resident #146 was observed in his room seated on his bed. The floor in the room was covered with urine because the resident had urinated on the floor in front of his bed, placing the resident at risk of falling. The surveyor immediately called the nurse and the housekeeping staff who came immediately to clean the room. The resident appeared anxious and agitated. Review of the clinical records for Resident #146 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but are not limited to, Other Sepsis; Unspecified Psychosis not Due to a Substance or Known Physiological Condition; Major Depressive Disorder, Recurrent, Unspecified; Type 2 Diabetes Mellitus without Complications. Review of Resident #146's PASRR Level I dated 03/14/2023 revealed identification of a mental diagnosis under 1A. Section 1B was checked for Serious Mental Illness. Section 4 revealed the individual had no diagnosis or suspicion of serious mental illness (SMI) or intellectual disability (ID) indicated. Level II PASRR evaluation not required. Review of Resident #146's physician orders dated 12/08/2021 revealed the resident was receiving Temazepam Capsule 15 milligrams *Controlled Drug*, 1 capsule by mouth at bedtime related to Insomnia, Unspecified. Orders dated 12/08/2021 revealed the resident was receiving Quetiapine Fumarate tablet 300 milligrams; 1 tablet by mouth at bedtime related to Unspecified Psychosis not due to a Substance or known Physiological Condition. Orders dated 01/16/2022 revealed the resident was receiving Lorazepam tablet 0.5 milligrams. *Controlled Drug*; 0.5 milligrams by mouth two times a day for Anxiety. Orders dated 01/18/2022 revealed the resident was receiving Haloperidol tablet 10 milligrams; 10 milligrams two times a day related to Unspecified Psychosis not due to a Substance or known Physiological Condition. Orders dated 04/23/2022 revealed the resident was receiving Buspirone HCL tablet 15 milligrams: 1 tablet by mouth three times a day for Anxiety. Orders dated 04/23/2022 revealed the resident was receiving Quetiapine Fumarate tablet 100 milligrams: 1 tablet by mouth in the morning for Unspecified Psychosis. Orders dated 09/29/2022 revealed the resident was receiving Depakene Solution 250 milligrams/5 milliliters (Valproate Sodium): 5 milliliters by mouth every 8 hours related to Anxiety Disorders, Unspecified. Orders dated 02/26/2023 revealed the resident was receiving Levetiracetam Solution 100 milligrams /milliliters; 15 milliliters by mouth every 12 hours related to Anxiety Disorders, Unspecified. Review of the Medication Administration Record for March 2023 revealed the resident was receiving medications as ordered. Review of Resident #146's Quarterly Minimum Data Set (MDS) Section C for Cognitive Patterns dated 01/28/2023 revealed the Brief Interview for Mental Status (BIMS)summary score was 04 of 15 indicating the resident severely impaired cognitively. Section I for Active Diagnosis dated 01/28/2023 revealed the resident's diagnosis were Anxiety, and Psychotic Disorder. Section N for Medications revealed the resident was receiving antipsychotics, antianxiety and hypnotic medications. Review of Resident #146's Care Plan initiated on 10/21/2021 and next review date 04/30/2023 revealed the resident was at risk for drug related side effects due to use of psychotropic medications. Goal: The resident will remain free of drug related side effects through the next review date. Interventions: Assess for fall risk and precautions needed. Encouraged activities as tolerated. License Nurse to follow/up behavior monitoring sheet. Medicated as ordered. Psychiatrist consultation/evaluation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 18 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as needed. Monitored behavior and mood every shift and documented. Monitored for adverse side effects of drugs (lethargy, dizziness, increase in confusion, gait disturbance). Monitored for behavior/mood changes. Notify Social Services Director about any changes in behavior pattern. Observed for decline in function. Physical/Occupational therapy as needed. Reported changes to physician as needed. Review of Resident #146's Behavior Notes dated 02/09/2022 revealed Around 08:00 AM placed call to physician regarding aggressive behavior toward roommate. New order received for psychiatrist consult and 1:1 monitoring until seen by psychiatrist. Review of Resident #146's Behavior Notes/Progress Note/Consult date 02/12/2022 revealed resident with multiple comorbidities medical conditions, and previously diagnosed as Unspecified Psychosis, Anxiety disorder and insomnia was seen for psychiatrist consult, continuity of care and supportive therapy. Resident is room reported involved in an altercation between residents; otherwise maintained good sleep and appetite, with continue improvement of mood/psychotic signs and symptoms; appeared alert and oriented to person and place, calm and passive on approach, with periods of confusion, no overt/elicited psychosis, in no apparent distress at present. Treatment plan: Continue current treatment. Encouraged the resident to participate in activities to encourage cognitive functions. Monitored mood, behavior, sleep, and appetite. Continue psychotherapy as indicated. Medication change: No changes currently. During an interview with Staff G, a Licensed Practical Nurse (LPN) on 03/24/2023 at 11:20 AM; Staff G stated that Resident # 146 urinated on his room floor many times. She encouraged him to call for assistance every time he was going to go to the bathroom, but he continued to do it. The resident had behaviors and there was no way to redirect him. 6) Observation of Resident #118 on 03/23/2023 at 9:15 AM. The Resident was observed sleeping with tube feeding in place and running. On 03/24/2023 at 08:15 AM, Resident # 118 was observed sleeping with tube feeding in place running and no distress noted. Record review of the clinical records for Resident #118 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but are not limited to, Other Specified Sepsis; Type 2 Diabetes Mellitus without Complications; Unspecified Psychosis not due to a Substance or Known Physiological Condition; Major Depressive Disorder, Recurrent, Unspecified. Record review of Resident #118's PASRR Level I dated 03/14/2023 revealed identification of a mental diagnosis under 1A. Section 1B was checked for Serious Mental Illness. Section 4 revealed the individual had no diagnosis or suspicion of serious mental illness (SMI) or intellectual disability (ID) indicated. Level II PASRR evaluation not required. Review of Resident #118's orders dated 01/31/2023 revealed the resident was receiving Trazodone HCL Oral tablet 100 milligrams; 1 tablet via tube feeding at bedtime related to Major Depressive Disorder, Recurrent, Unspecified. Orders dated 01/31/2023 revealed the resident was receiving Risperidone oral tablet 3 milligrams; 3 milligrams via tube feeding two times a day related to Unspecified Psychosis not due to a Substance or Known Physiological Condition. Orders dated 01/31/2023 revealed the resident was receiving Trazodone HCL Oral tablet 50 milligrams. Give 1 tablet via tube feeding one time a day related to Major (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 19 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Depressive Disorder, Recurrent, Unspecified. Review of the Medication Administration Record for March 2023 revealed the resident was receiving medications as ordered. Record review of admission Minimum Data Set (MDS) Section C for Cognitive Patterns dated 02/07/2023 revealed the Brief Interview for Mental Status (BIMS)summary score was 12 of 15 meaning the resident moderately impaired cognitively. Section I for Active Diagnosis dated 02/07/2023 revealed the resident's diagnosis were Depression and Psychotic Disorder. Section N for Medications revealed the resident was receiving antipsychotics and antidepressant medications. Review of Resident #118's Care Plan initiated on 01/31/2023 and the next review date 05/21/2023 revealed the resident was at risk for drug related side effects due to use of psychotropic medications: Depression and Psychosis. Goal: the resident will remain free of drugs related side effects through next review date. Interventions: Assess for fall risk and precautions needed. Encouraged activities as tolerated. License Nurse to follow/up behavior monitoring sheet. Medicated as ordered. Psychiatrist consultation/evaluation as needed. Monitored behavior and mood every shift and documented. Monitored for adverse side effects of drugs (lethargy, dizziness, increase in confusion, gait disturbance). Monitored for behavior/mood changes. Notify Social Services Director about any changes in behavior pattern. Observed for decline in function. Physical/Occupational therapy as needed. Reported changes to physician as needed. Interview with Staff E, a Licensed Practical Nurse (LPN) on 03/24/2023 at 09:15 AM. Staff E stated the resident was admitted recently. The resident was quiet and tolerated the medications well and did not get out of his bed and slept a lot, and had no aggressive behavior since he was admitted . 7) Observation of Resident #120 on 03/23/2023 at 10:10 AM, revealed the resident in bed watching television. No distress or anxiety was noted. On 03/24/2023 at 02:10 PM, Resident #120 was observed seated in his wheelchair on the patio interacting with another resident. No distress or anxiety was noted. Review of the clinical records for Resident #120 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include, but not limited to, Metabolic Encephalopathy; Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Unspecified Psychosis not due to a substance or Known Physiological Condition; Anxiety Disorder, Unspecified; Other Symptoms and signs involving Appearance and Behavior. Record review of Resident #120's Level I Preadmission Screening of Resident Review (PASRR) dated 03/14/2023 Section I Screen Decision Making Section A was marked as the resident had diagnosis of mental illness, it revealed the resident had currently receiving services for Mental Illness. Section II for other indicators for PASRR had no response. Section III PASRR Provisional admission revealed the resident was not a provisional admission. Section IV PASRR Screen Completion stated the resident had no mental illness or suspicion. Record review of orders dated 06/03/2022 revealed Resident #120 was receiving Quetiapine Fumarate tablet 100 milligrams. Give 2 tablets by mouth two times a day for Unspecified Psychosis. Record review of Medication Administration Record for the month of March revealed the resident was receiving medications as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 20 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0645 Level of Harm - Minimal harm or potential for actual harm Record review of Quarterly Minimum Data Set (MDS) Section C or Cognitive Patterns dated 03/08/2023 revealed the Brief Interview for Mental Status (BIMS)summary score was 09 out of 15 indicating moderate cognitive impairment. Section I for Active Diagnosis dated 03/08/2023 revealed the resident's diagnosis was Psychotic Disorder. Section N for Medications revealed the resident was receiving antipsychotics medications. Residents Affected - Some Record review of Resident #120's Care Plan initiated on 06/01/2022 and the next review date 06/10/2023 revealed the resident was at risk for drug related side effects due to use of psychotropic medications. Diagnosis: Psychosis. Goal: The resident will remain free of drug related side effects through the next review date. Interventions: Assess for fall risk and precautions needed. Encouraged activities as tolerated. License Nurse to follow/up behavior monitoring sheet. Medicated as ordered. Psychiatrist consultation/evaluation as needed. Monitored behavior and mood every shift and documented. Monitored for adverse side effects of drugs (lethargy, dizziness, increase in confusion, gait disturbance). Monitored for behavior/mood changes. Notify Social Services Director about any changes in behavior pattern. Observed for decline in function. Physical/Occupational therapy as needed. Reported changes to physician as needed. Record review of Resident #120's Behavior Notes dated 10/17/2022 revealed the resident stated, I am going to punch my roommate in his face, when ask what happen, he stated I don't want to be disturbed Resident transferred to a different room. Psychologist and Psychiatrist came to see resident. The resident was calm in his new room. Will continue to monitor resident behavior. Interview with Staff D, Licensed Practical Nurse (LPN) on 03/24/2023 at 03:25 PM. Staff D stated the resident was a pleasant resident but sometimes he got agitated and yelled at the staff, and had to be redirected and wait until he calmed down. Staff D explained that the resident got better after the medication was administered. During an interview with the Social Services Director on 03/24/2023 at 12:15 PM. The Social Services Director stated that the admission Department oversees PASRR before a resident is admitted . She stated she started to work at the facility as Social Services Director on March 6, 2023 and the admission Director and the Director of Nursing took care of Level I PASRR for residents to be admitted . During an interview with the admission Director on 03/24/2023 at 12:20 PM. The Admission's Director stated that when a resident is admitted the hospital sends the Level I PASRR to them (the facility) to review the form is checked to ensure it is completed, and the diagnosis is on the form. If the form is not completed, it is sent back to the hospital. Then the Director of Nursing and the Assistant Director of Nursing would oversee reviewing the Level I PASRR, before the resident is admitted . The Director of Nursing and Assistant Director of Nursing revealed during an interview on 03/24/2023 at 12:48 PM; that the facility protocol for Level I PASRR was the hospital sends the form to the admission Department to review and to check if the form is completed with diagnosis and resident's [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 21 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 interview, the facility failed to implement a written care plan related to skin integrity and dental for one resident (Resident # 91) out of 38 sampled residents. The findings included: 1) Observation and interview of Resident # 91 on 3/21/2023 at 9:16 AM revealed the resident lying in bed, wearing glasses and was missing top and lower teeth. The resident was scratching his arms and abdomen area. He lifted the blanket and showed bumps on his arm and abdomen area. He revealed via a Spanish translator that he had been itching and was not receiving anything for it. He revealed he had not seen the dentist and would like to see one. Review of the Demographic Face Sheet for Resident #91 documented the resident was admitted on [DATE] with a diagnoses to include diabetes mellitus, insomnia, hypertension, Hyperlipidemia and major depressive disorder. Review of the Physician's Order Sheets (POS) for Resident # 91 dated January 2023, February 2023, March 2023 documented no orders for dental consult, weekly skin check every Wednesday and no medication for itching was noted. The resident had an order on 3/20/2022 for Ketoconazole Gel 2% to apply to affected areas .topically in the morning for itching related to diabetes mellitus for two weeks. The order was not renewed. Review of Resident #91's skin integrity care plan dated 10/20/2021 documented the resident was at risk for alteration in skin integrity; Goal: Will maintain skin integrity with daily skin prevention through the next review date; Intervention: Inspect skin daily for any changes and notify nurse as needed; Monitor skin daily during care and report first signs of breakdown; Weekly skin audit. Review of Resident # 91's dental care plan dated 10/10/2022 documented the resident exhibits likely or obvious dental caries or broken teeth, missing teeth; Goal: Will not develop any oral/dental complications through next review date; Interventions: Dental consult and treatment as needed and ordered. Review of the Weekly Skin Audit for Resident n# 91 dated 3/16/2023 documented the following: Skin is intact with no open area at this time. There was no weekly skin audit conducted on 3/22/2023. Review of the Weekly Skin Summary for Resident # 91 dated 3/16/2023 documented the following: Skin Condition: Other skin problems-No boxes were checked. There was no weekly skin summary conducted on 3/22/2023. Review of the Dental Consult for Resident #91 revealed there was no dental consult noted in the resident's chart. A dental consult for the resident was received from the Social Services Director on 3/24/23. The resident last received a dental consult on 2/08/2021. Interview with the Social Services Director on 3/24/2023 at 10:14 AM. She stated, He was seen by the dentist on 2/08/2021. He didn't say he wanted to go to the dentist. I will speak to him about seeing the dentist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 22 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 Interview and record review with Staff D, Licensed Practical Nurse (LPN) on 3/24/2023 at 11:57 AM. She stated, He is alert and oriented times two. He is limited assistance for ADLs. No medications for itching were prescribed for the resident. I did the skin check weekly. I never seen anything on his arms but he had red marks on his stomach. Last week when I checked him, I didn't see anything. Interview with the Director of Nursing (DON) on 3/24/2023 at 3:38 PM. She stated, The resident had an order on 3/20/2022 for Ketoconazole Gel 2% to apply to an affected areas .topically in the morning for itching related to diabetes mellitus for two weeks. We called the doctor today and he gave an order to continue with the gel and ordered a dermatologist consult. Review of the facility's policy titled Care Plans dated 3/1/21 states: It is the policy of the facility to create Care plans in accordance to State and Federal regulations. Procedure 2: The care plan must consist of a physician's order, diagnosis, medical history, physical exam and rehabilitative or restorative potential. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 23 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide treatment and care related to skin integrity for one resident (Resident # 91) out of one resident reviewed for skin conditions. Residents Affected - Few The findings included: Observation and interview of Resident # 91 on 3/21/2023 at 9:16 AM revealed the resident lying in bed. The resident was scratching his arms and abdomen area. He lifted the blanket and showed bumps on his arm and abdomen area. He revealed via a Spanish translator that he had been itching and was not receiving anything for it. Review of the Demographic Face Sheet for Resident # 91 documented the resident was admitted on [DATE] with a diagnoses to include diabetes mellitus, insomnia, hypertension, hyperlipidemia and major depressive disorder. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident # 91 dated 1/08/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating mild cognitive impairment and the resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living). Review of the Physician's Order Sheets (POS) for Resident # 91 dated January 2023, February 2023, March 2023 documente weekly skin check every Wednesday and no medication for itching was noted. The resident had an order on 3/20/2022 for Ketoconazole Gel 2% to apply to an affected areas .topically in the morning for itching related to diabetes mellitus for two weeks. The order was not renewed. Review of Resident number 91's skin integrity care plan dated 10/20/2021 documented the resident was at risk for alteration in skin integrity; Goal: Will maintain skin integrity with daily skin prevention through the next review date; Intervention: Inspect skin daily for any changes and notify nurse as needed; Monitor skin daily during care and report first signs of breakdown; Weekly skin audit. Review of the Weekly Skin Audit for Resident # 91 dated 3/16/2023 documented the following: Skin is intact with no open area at this time. There was no weekly skin audit conducted on 3/22/2023. Review of the Weekly Skin Summary for Resident # 91 dated 3/16/23 documented the following: Skin Condition: Other skin problems-No boxes were checked. There was no weekly skin summary conducted on 3/22/23. Interview and record review with Staff D, Licensed Practical Nurse (LPN) on 3/24/2023 at 11:57 AM. She stated, He is alert and oriented times two. He is limited assistance for adls. No medications for itching were prescribed for the resident. I did the skin check weekly. I never seen anything on his arms but he had red marks on his stomach. Last week when I checked him, I didn't see anything. Interview with the Director of Nursing (DON) on 3/24/23 at 3:38 PM. She stated, The resident had an order on 3/20/22 for Ketoconazole Gel 2% to apply to an affected areas . topically in the morning for itching related to diabetes mellitus for two weeks. We called the doctor today and he gave an order to continue with the gel and ordered a dermatologist consult. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 24 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Observation on 03/21/2023 at 07:29 AM revealed, Resident #134 in bed asleep, the resident had tube feeding infusing at 45 cc(cubic centimeters)/hour, a water flush 40 cc/hr. The resident was receiving Oxygen at 1 1/2 liters/minute via nasal cannula, with a humidifier bottle dated 3/12, the bag on O2 canister was dated 3/12. Residents Affected - Few Observation of Resident #134 on 03/24/2023 at 02:00 PM, revealed the resident was receiving oxygen at 1 1/2 liters via nasal cannula. On 03/24/2023 at 02:12 PM, Staff G, Licensed Practical Nurse and Unit Manager for the [NAME] unit was asked to check the oxygen order for Resident #134, she checked the electronic medical record and reported the oxygen was ordered for 2 liters/min and she was asked to check the residents oxygen concentrator. Staff G acknowledged the oxygen was set at 1 1/2 liters/min. She then increased the oxygen to 2 liters. During the review of Resident #134's Physicians orders, the resident had a physician order for oxygen at 2 liters via nasal cannula continuous. The residents Quarterly MDS assessment reference date was 3/5/2023, did not document the use of oxygen in section O 100. The resident admission MDS assessment reference date was 12/3/2022 documented in section O 100 oxygen was in use. Review of the residents care plan for At risk for ineffective breathing pattern related to: Pulmonary Edema and Respiratory Failure. With a goal of [Resident #134] will demonstrate an effective respiratory rate, depth and pattern, increase activity tolerance and no stated discomfort thru NRD (next review date). Adjust head of bed and body positioning to assist ease of breathing. Administer medication/oxygen as ordered. Arrange activities to allow adequate rest and increase activities as tolerated. Instruct resident in relaxation techniques. Keep head of bed elevated to facilitate easy respirations. Monitor lab reports and refer to MD. Monitor lung sounds, pallor, cough and character of sputum. Monitor resident's anxiety and give support/assistance as needed. Based on observations, interviews, and record review the facility failed provide respiratory services to meet professional standards for two residents (Resident #118 and Resident #134) out of the 38 sampled residents. Resident # 118 was receiving oxygen without a physician's order and Resident # 134 oxygen was not being administered at the rate ordered by the physician. The findings included: 1) During observation on 03/20/23 at 07:44 AM Resident #118 was observed in bed asleep with tube feeding in place and infusing. The resident was receiving oxygen at 2 liters per minute via nasal cannula. On 03/20/2023 at 10:19 AM Resident # 118 was observed in room awake and oxygen running at 2 liters per minute via nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 25 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm During an observation on 03/20/23 at 10:21 AM Resident #118 was observed in bed awake. The resident did not respond to questions. On 03/21/2023 at 07:36 AM Resident #118 was observed in bed with 02 running at 2 liters per minute via nasal cannula no distress noted. Residents Affected - Few On 03/22/2023 at 07:39 AM, Resident 118 was observed in bed with 02 running at 2 liters per minute via nasal cannula. Review of the medical records for Resident #118 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Influenza due to other identified influenza virus with other respiratory manifestations, Other specified sepsis and Dysarthria and Anarthria. Review of Resident #118's Physician's Orders Sheet for March 2023 revealed, there were no orders for oxygen in the resident's records until 03/22/2023. The order was for oxygen at 2 liters per minute via nasal cannula continuously every shift for shortness of breath. Record review of Resident #118 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented the resident's Brief Interview for Mental Status Score (BIMS) is 12 out of 15 indicating the resident is moderately impaired. Section G for Functional Status documented the resident requires total dependence for activities of daily living with one person assistance. Section J for Health Conditions documented the resident experiences shortness of breath or trouble breathing with exertion. Section O-for Special Treatments, Procedures, and Programs documented the resident received oxygen in the last 14 days. Record review of Resident #118 's Care Plans Reference Date 01/31/2023 revealed: Resident is at risk for ineffective breathing pattern related to: history of COVID and flu. Resident will demonstrate an effective respiratory rate, depth, and pattern, increase activity tolerance and no stated discomfort through next review date. Interventions include but not limited to: Adjust head of bed and body positioning to assist ease of breathing. Administer medication/oxygen as ordered. Keep head of bed elevated to facilitate easy respirations .Monitor respiratory rate, depth, and effort. During an interview on 03/22/2023 at 08:13 AM, Licensed Practical Nurse (Staff A) stated: Today is my first day working on this side. When Staff A was asked about the oxygen order for Resident # 118, Staff A stated, I will look it up. Staff A could not find an order for 02 to be administered to Resident #118. Staff A stated: I saw the resident this morning on my rounds, he has his oxygen on, I received report from the off going Agency Registered Nurse (Staff O) and she stated everything was fine in my area. Interview on 03/22/2023 at 08:40 AM Registered Nurse, Staff B stated, I am going to find out what happened, I am going to call the resident's doctor (MD) to see if the resident needs oxygen, the resident's oxygen saturation currently is 98 on oxygen via nasal cannula, we are going to remove the oxygen for 30 minutes to see how the resident 02 saturation is and let the MD know. Interview on 03/22/2023 at 08:46 AM, the Registered Nurse Supervisor for the D Wing, Staff C stated: This resident was just transferred to my unit a couple weeks ago, I will need to double check his orders, what I will do is call the MD and go from there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 26 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm On 03/22/2023 at 08:48 AM Registered Nurse, Staff B stated: I spoke to the resident's Physician Assistant (PA) and explained the situation concerning the residents' oxygen, the PA said to keep the oxygen on continuously. The PA ordered a chest x-ray and prescribed Albuterol every 8 hours, and oxygen at 2 liters per minute via nasal cannula continuously. We took him off the oxygen for a test and in 5 minutes the resident desaturated to 93. Residents Affected - Few Review of the facility's policy titled Respiratory Care and Oxygen Administration revised 10/2022 states: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guidelines: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube/PleurX care, non-invasive ventilation system (BiPAP), continuous positive airway pressure (CPAP) or medication Administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 27 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure dental service was provided for one resident (Resident # 91) out of one resident reviewed. This practice has the potential to affect all 207 residents present in the facility at the time of the survey. Residents Affected - Few The findings included: Record review of the facility's policy titled, Dental Services (written 3/2021) documented the following: Policy: It is the policy of the facility to provide Dental Services in accordance to State and Federal regulations; Procedure: 1) The facility will provide from an outside source routine and emergency dental services to meet the needs of each resident; 2) The facility will provide necessary assist the resident by: a) making appointments and b) arranging for transportation to and from the dentist's office. Review of the facility's policy titled, Social Services (written 3/2021) documented the following: Policy: It is the policy of the facility to provide Social Services in accordance to State and Federal regulations; Procedure: 2) The facility will provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. These service might include: d) Making referrals and obtaining services from outside entities. Observation and interview of Resident #91 on 3/21/2023 at 9:16AM revealed the resident lying in bed, wearing glasses and was missing top and lower teeth. He revealed via a Spanish translator he had not seen the dentist and would like to see one. Review of the Demographic Face Sheet for Resident #91 documented the resident was admitted on [DATE] with a diagnoses to include diabetes mellitus, insomnia, hypertension, hyperlipidemia and major depressive disorder. Review of the Minimum Data Set (MDS) admission Assessment for Resident # 91 dated 10/08/2022 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living), dental none of the above were marked. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident # 91 dated 1/08/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living), Supervision with setup help only for eating and required a Mechanically altered diet. Review of the Physician's Order Sheets (POS) for Resident # 91 dated January 2023, February 2023, March 2023 documented no orders for a dental consult. Review of Resident #91's dental care plan dated 10/10/2022 documented the resident exhibits likely or obvious dental caries or broken teeth, missing teeth; Goal: Will not develop any oral/dental complications through next review date; Interventions: Dental consult and treatment as needed and ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 28 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Dental Consult for Resident # 91 revealed there was no dental consult noted in the resident's chart. A dental consult for the resident was received from the Social Services Director on 3/24/23. The resident last received a dental consult on 2/08/2021. Interview with the Social Services Director on 3/24/2023 at 10:14 AM. She stated, He was seen by the dentist on 2/08/2021. He didn't say he wanted to go to the dentist. I will speak to him about seeing the dentist. Event ID: Facility ID: 106133 If continuation sheet Page 29 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review the facility failed to assure the garbage and refuse area was clean and flattened cardboard boxes were properly disposed and contained on the facility grounds. Residents Affected - Few The findings included: Record review of the Dietary Disposal of Garbage and Rubbish Policy and Procedure (dated 3/01/2021) documented: Policy: It is the policy of the facility to provide care and services related to the disposal of garbage and rubbish in accordance with State Requirements; Procedure: 7) Garbage should not accumulate or be left outside the dumpster. Observation of the outside of the facility near the garbage and refuse area with the Food Service Director (FSD) on 3/20/2023 at 6:28 AM. The area had two garbage bins with one used for garbage and one for recyclables. There were fourteen flattened cardboard boxes leaning against the wall on the ground and not contained in the recycling bin. Photographic evidence submitted. Interview with the FSD on 3/20/2023 at 6:29 AM. She stated, We are not responsible for these boxes on the ground. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 30 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure complete and accurate documentation of resident's Advanced Directives for 1 (Resident #175) out of 38 sampled residents. The findings included: During observation on 03/20/23 at 07:55 AM Resident # 175 was observed in bed. The head of bed the bed was elevated, tube feeding was running at 50 milliliters per hour (ml/hr.), flush at 50 ml. Oxygen (02) was in place and running at 2 Liters per minute (LPM)via nasal cannula. On 03/21/23 at 08:26 AM Resident # 175 was observed in bed, with the head of the bed elevated, the tube feeding was off, and oxygen was running at 2 LPM via nasal cannula. No distress noted. On 03/22/23 at 07:36 AM Resident #175 was observed in bed asleep, the tube feeding was running, and oxygen was in place at 2 LPM via nasal cannula. Review of the medical records for Resident #175 revealed Resident #175 was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Osteomyelitis, unspecified. Review of Resident # 175's Physician's Orders Sheet for March 2023 documented orders dated 02/2/2023 Full Code Status and on the profile page on the electronic health records Full code was documented. Record review of Resident #175 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score was unable to be determined. Section G For Functional Status documented resident is total dependence for Activities of Daily Living (ADLS) with one person assistance. Record review of Resident #175 's Care Plans revealed: no documentation regarding advanced directives. Further review of the medical records for Resident #175 revealed the resident had a Do Not Resuscitate (DNR), order on file signed by MD on 12/30/2022. On 03/23/2023 at 02:57 PM during an interview, the Social Services Director (SSD) reported that the DNR on file is not valid because the resident's representative did not sign it, it needs to be signed by both the Medical Doctor (MD) and the resident or resident representative. The DNR was signed by the MD on 12/30/2022. When asked if there is any documentation noting if the resident's representative was contacted or attempts made to contact the resident's representative regarding the DNR signature request. The Social Services Director stated she will check the computer system. The Social Services Director was unable to find any documentation on file regarding resident's representative being contacted to sign the DNR document. Review of the facility policy and procedure titled Advanced Directives dated 3/1/2021 states: The facility will provide each adult individual, at the time of admission as a resident, with written information concerning the nursing home's policies respecting advance directives; and provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 31 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0842 documentation of the existence of an advance directive within the medical record. 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: 106133 If continuation sheet Page 32 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain communication with hospice to ensure continuation of care for 1 (Resident #153) out of 6 residents on hospice care, as evidenced by no updated hospice communication notes available in Resident #153's medical records. This had the potential to affect the 207 residents residing in the facility at the time of this survey. The Findings Included: During observation on 03/20/2023 at 06:47 AM resident in bed asleep, call light on bed, no distress noted. On 03/21/2023 at 08:25 AM Resident #153 was observed in bed asleep, no distress noted. On 03/22/2023 at 07:30 AM Resident #153 was observed in bed asleep, no distress noted. On 03/22/2023 10:42 AM Resident #153 observed in wheelchair in room, rolling around, no distress noted. On 01/18/2023 at 08:36 AM Resident #153 was observed in bed asleep. Tube feeding running at correct rate, no distress noted. Review of Resident #153's hospice contract documented: 11/14/2014 hospice contract effective, signed by [Hospice Company] General Manager and the Nursing Home Administrator (NHA). Review of the available hospice notes for Resident #153 revealed a note dated 02/03/2023 to be the most recent hospice note. The other notes available in the hospice communication hospice binder were dated: 01/10/23, 11/01/2022, 07/08/2022, 06/20/2022 Psychosocial /Spiritual updated comprehensive assessment and 06/16/2022-Do not resuscitate order effective. Further review of the medical records for Resident #153 revealed the resident was admitted to the facility on [DATE] and admitted to hospice on 09/30/2022. Clinical diagnoses included but not limited to: Encounter for Palliative Care. 06/16/2022 Do Not Resuscitate (DNR), and-Hospice Care. Record review of Resident #153's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) 6, on a 0-15 scale indicating the resident has severe cognitive impairment. Section G for Functional Status documented resident required supervision for eating, and extensive assistance for all other Activities of Daily Living (ADLs) with one person assistance. Section O for Special Treatments, Procedures, and Programs documented that the resident received hospice care in the last 14 days. Record review of Resident # 153's Care Plans Reference Date 12/19/2022 revealed the resident has a DNR and is receiving hospice services. Resident care will be coordinated between the integrated efforts of Hospice and facility staff daily through the next review date. Interventions Include: Evaluate need for additional staff as need to meet the resident's needs. Hospice nurse will assist in coordinating the needs of the resident. Hospice will ensure that continued residency is agreeable to resident, representative, and the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 33 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/23/2023 at 12:20 PM, Registered Nurse Supervisor D unit (Staff C) was asked about hospice services and hospice communication notes, Staff C stated: There is a binder that we use for hospice to sign when they come to the facility, and they discuss any areas of concern with the staff here before they leave. Hospice staff visits at least 2 to 3 times a week, I see the Hospice Certified Nursing assistant (CNAs) more often. They sign in, in the hospice book and leave their notes in the book after a visit. On 03/23/2023 at 12:57 PM, reviewed the hospice communication book for Resident #153 from staff, was dated 02/03/2023 as the most recent hospice communication notes available in hospice binder. Review of the Facility's Policy and Procedure titled Hospice Program, revision date January 2014, stated: When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 34 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices cited during this survey for: F585-Grievances F623- Notice Requirements Before Transfer/Discharge; F641 Accuracy of Assessments; F645 PASARR Screening; F695 Respiratory/Tracheostomy Care and Suctioning; F761 Label/Store Drugs and Biologicals; F849 Hospice Services. These repeat deficient practices has the potential to affect 207 residents residing in the facility at the time of survey. The finding included: Record review of the facility's survey history revealed, during a recertification conducted on December 6, 2021, through December 9, 2021 the facility was cited F623 Notice Requirement before Transfer/Discharge was cited as the facility failed to provide the Nursing Home Notice of Transfer Discharge to the resident and or representative and the office of the Long-Term Care Ombudsman; F641 Accuracy of Assessments due to failure to accurately code the minimum data set (MDS); F645 due to the facility's failure ensure each resident was screened for a Preadmission Screening and Resident Review (PASRR) Level I for a Serious Mental Illness (SMI) or Intellectual Disability (ID) prior to admission for one resident; F695 was was cited as the facility failed to provide appropriate Respiratory and Tracheostomy care services related to failure to provide tracheostomy care for one Resident by not changing a resident's tracheostomy collar for two weeks and failed to ensure appropriate handling of nasal cannula and administration of oxygen; F761 for failure to provide safe and secure storage of biologicals; F849 for failure to coordinate care related to hospice services. During a complaint survey with exit dated 08/03/2022 the facility was cited F585 for grievances related to the facility's failure to address and resolve grievance/ concern voiced by a resident. In an interview with the facility's Administrator on 03/24/2023 at 3:44 PM. She stated that Quality Assurance and Performance Improvement (QAPI) meetings are held on the third Wednesday of every month. The members of the QAPI committee were the Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, Social Services Director, Minimum Data Set (MDS) Coordinator, Dietary Director, Activities Director, admission Director, Maintenance Director, Housekeeping Director, Department Heads. The Administrator was informed of repeat deficient practices and identified concerns. The Administrator revealed they were ensuring all residents have the correct Level I and II of PASRR and the issues with PASRR Level I and Level II will be solved soon. The facility had grievance deficiencies in the past and the facility hired a new Social Services Director, and she was receiving education training. For Advance Directives, bed hold and discharge, resident assessment, Care Plan issues, Respiratory Care, Pharmacy Procedures and Storage, and Infection Control. The administrator acknowledged the concerns and revealed plans to correct will include audits and education. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 35 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow Infection Prevention and Control Policies and Procedure. This affected 1) One (1) out of 41 residents receiving Accuchecks/blood glucose monitoring (Resident #136). The facility failed to appropriately clean and disinfect a blood glucose monitoring device that was being used for multiple residents. The likelihood existed for cross contamination, increased risk for exposure and being infected with a blood borne pathogen through the use of the contaminated blood glucose monitoring device. 2) Three (3) out of 7 residents on Isolation Precautions (Resident #119, Resident#195, Resident #265). Staff were observed entering resident rooms without putting on proper Personal Protective Equipment (PPE). 3) Two (2) out of 33 residents on the [NAME] unit had a blood appearing substance on the floor and on a blanket (Resident #134 and Resident #9). 4) Two (2) out 33 residents on the [NAME] unit were observed with an overflowing biohazard garbage container with a red bag and an overflowing regular garbage container in their rooms (Resident #136 and Resident #195). Residents Affected - Few At the time of the survey, the facility had 11 residents with diagnoses of Bloodborne Pathogens. This deficient practice had the potential to affect 207 residents admitted to the facility at the time of the survey. Based on the findings with Resident #136 on 3/22/2023, it was determined the findings represented Immediate Jeopardy (IJ) to the health and safety of the residents. After receiving an acceptable IJ Removal Plan, it was determined the IJ had been removed effective 3/23/2023. The findings included: 1. On 03/22/2023 at 8:25 AM, a medication observation was completed with Staff H, Registered Nurse from a staffing agency on the [NAME] Unit/G-Unit. Staff H was observed to take the resident, blood pressure, administer Simethicone 80 mg, 1 tab crushed, via the Percutaneous Gastrostomy Tube (PEG) mixed with 30 cc (cubic centimeters) of water, and gave medication in 60 cc of water, a small amount of medication remained in the medicine cup and 10cc of water was added to give the remaining crushed medication, then the PEG was flushed with 30 cc water. Staff G, Licensed Practical nurse Unit Manager used hand sanitizer, put on gloves, clean Resident #136's finger with an alcohol prep pad, pricked the residents finger and used the [BRAND NAME]multi PERSON USE Blood Glucose Monitoring System. The glucose level was 129. Staff H administered Glargine Insulin Pen subcutaneously into Resident #136 right abdomen. Staff H took the needle off the insulin pen and took it to the medication cart sharps container instead using the sharps container in the resident's room. Staff H was not observed to clean the glucose monitoring device at the resident's bedside and brought the device out of the resident's room and placed it in a top drawer on the medication cart. Staff H signed out the administration of the Simethicone 80 mg, but did not add the glucose level of to the electronic medical record. Staff G, Licensed Practical Nurse (LPN), Unit Supervisor was standing near the medication cart and explained, this was an extra glucose monitoring, and it did not need to be documented. This glucose monitoring was completed to check the glucose prior to administering the Glargine insulin. On 3/22/2023 at 9:15AM, Staff H was asked, Did you clean the glucometer/glucose monitoring device? Staff H replied, she cleaned it. Staff H was asked when she cleaned the glucometer. Staff H replied, stating that she cleaned it while she was in the resident's room. Staff H was asked what she did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 36 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few cleaned it with, and she replied: with an alcohol wipe. When asked to show what she used, Staff H opened the top drawer of the medication cart, and took out an alcohol wipe. Staff G was standing next to the medication cart and intervened and explained to Staff H that this was incorrect. Staff G demonstrated cleaning the glucose monitoring device with the purple top, [brand] Medical and Commercial Disinfecting Wipes for Virucidal, Bactericidal, Fungicidal, Pseudomonad, Tuberculocidal on environmental surfaces. On 3/22/2023 from 9:27AM to 10:34AM, 5 additional residents medication observations were completed on [NAME] wing (AC) medication Cart, the (A) wing, the (D) wing, and the East wing. There was no additional glucose monitoring completed during these observations. Review of the facility's policy and procedure for Disinfecting Glucometers dated 4/18/2020 documents, the title of the policy is Cleaning and Disinfecting Policy: It is the policy of the facility to clean and disinfect multi-patient use blood glucose meters. Resident to resident transmission of blood-borne pathogens is a well-known risk when using lancets, needles, and syringes. Blood glucose monitors that are shared among residents must be cleaned and disinfected. Procedures: 1. Apply gloves before performing a blood glucose test. Glucose monitoring, administration of insulin, and any other procedure that involves potential exposure to blood or body fluids. 2. Dispose of used finger stick devices and lancets at the point of use in an approved sharps container. Do not reuse needles, syringes, or lancets. 3. Remove gloves and wash hands. 4. Apply new gloves. 5. Thoroughly clean and disinfect all visible soil or blood from glucometer with Sani-cloth. 6. If the Resident has C-Diff, thoroughly cleans, and disinfect all visible soil or blood from glucometer with PDI Orange Top Sani-Cloth Bleach Wipes. 7. Perform hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other residents. 8. Follow manufacturer's guidelines for cleaning and disinfecting of glucose meters. Specific guidelines for glucose meters may vary with the manufacturer. Keep glucometer wet for maximal kill time indicated on disinfecting agent product label. 9. In the absence of manufacturer's recommendations, the glucometer is considered a semi-critical device, follow policy for cleaning semi-critical devices. NOTE: When selecting a disinfecting cleaning product, review the required contact time. Nursing is to understand and demonstrate the necessary length of time the disinfectant must be in contact with the glucometer. Each disinfectant has specific instructions. You may have multiple shared (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 37 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 glucometers which are alternated between clean and disinfection status (i.e., Glucometer 1 is in use and then while glucometer 1 is being disinfected, glucometer 2 is in use.) Level of Harm - Immediate jeopardy to resident health or safety Staff H did not follow the facility's policy and procedures for Cleaning and Disinfecting Blood Glucometer. Residents Affected - Few Review of the blood glucose monitoring machine manufacturer's instructions revealed, Caring for the system documents, To minimize the risk of transmission of blood borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. After disinfection, users should remove gloves and wash hands before testing the next patient. And other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood borne pathogens. The meter should be cleaned and disinfected after use on each patient. The Blood Glucose Monitoring system may only be used for testing multiple patients on Standard Precautions and the manufacturers disinfection procedures are followed. Any disinfectant product containing these EPA registration numbers may be used on this device. Cleaning: 1. Wear appropriate protective gear such as disposable gloves. 2. Open the cap of the disinfectant container, pull out wipe. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 4. Dispose of the used towelette in the trash bin. The meter should be cleaned prior to each disinfection step. Note: No actual drying off the meter is required before starting the disinfecting procedure. Disinfecting: 5. Pull out 1 towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood borne pathogens. 6. Dispose of the used towelette in a trash bin. 7. Allow exteriors to remain wet for the corresponding contact time for each disinfectant. 8. After disinfectant, the users gloves should be removed to be thrown away and hands washed before proceeding to the next patient. Staff H did not follow the manufacturer's instructions for cleaning and disinfecting the facility's [Company/Brand Name] Multi, Blood Glucose Monitoring System. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 38 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2. Observation on 3/20/2023 at 6:27AM revealed Resident #195 and Resident #265, had a blue Stop sign and Special Droplet/Contact Precautions sign on their doors. The sign gave directions for only essential personnel should enter the room. Everyone must clean hands when entering and leaving the room. Wear a NIOSH [National Institute for Occupational Safety and Health] approved N95 or equivalent or higher-level respirator at all time, wear eye protection, gown, and glove at the door. A cart with Personal Protective Equipment was observed next to Resident #265's door. At 6:36 AM, Staff P, a Certified Nursing Assistant (CNA) was observed to enter Resident #265's room without a gown and gloves. Staff P was wearing a mask. Observation on 3/20/2023 at 6:55AM, Staff Q, a C N A was observed to go partially enter into Resident #195's room. Staff Q was observed to be wearing an N 95 mask, the staff member was not observed to use hand sanitizer or to put on a gown. Observation on 3/20/2023 at 7:56 AM, Staff Q entered Resident #195's room without putting on a gown. Staff Q was observed to come out of the room and put on a gown and went back into Resident #195's room. 3. Observation on 3/21/2023 at 7:29 AM in Resident #134's room, an alcohol wipe was observed on the floor, and it appeared to have blood on it. 4. Observation on 3/21/2023 at 8:07 AM, the biohazard garbage container with a red bag was overflowing with garbage in Resident #136's room. 5. Observation on 3/21/2023 at 8:19AM, a blood appearing substance was observed on Resident #9's blanket. 6. Observation on 3/21/2023 at 9:01 AM, Resident #119 had an isolation sign on the door with a stop sign, Modified Contact Precautions Everyone Must: Staff to sanitize hands before entering & upon exiting. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect shared equipment with bleach wipes. Resident #119 was diagnosed with Candida Auris. The Maintenance Director was observed to walk into Resident #119's room without sanitizing hands, and putting on a gown. The Maintenance Director was observed to leave the room without sanitizing his hands. On 3/21/2023 at 10:03 AM, the Maintenance Director was interviewed about entering Resident #119's room with no PPE. The Maintenance Director reported they are replacing the resident's mattress. He did not see the isolation signs until he was walking out of the door. He reports, he went to the nurses station about the door being open. The nurse told him the resident had been in isolation for over 10 days. On 3/22/23 at 1:15PM, Staff G, LPN, and Unit Supervisor was informed about staff entering the rooms of residents on isolation precautions without PPE for Resident #119, Resident #195 and Resident #265. On 3/22/23 at 1:45 PM Staff G , unit Managerreported Staff H had never worked on her unit before. Staff H had worked on other units. Staff G reports this morning she was trying to orient Staff H, but Staff H had already started taking care of the residents. Staff G reports, she was talking to Staff H about the type of residents on the unit. The unit was noted to have residents with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 39 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 tracheostomies, PEGs, and residents on isolation precautions. Level of Harm - Immediate jeopardy to resident health or safety 7. On 3/20/2023 at 6:00 AM, upon entrance into the facility and during tour of the facility a strong urine odor was noted. Residents Affected - Few During an observation on 3/24/2023 at 10:45 AM, a strong urine odor was noted on the G Wing. The surveyor knocked on Resident # 146's door and the resident responded yes, and the surveyor entered the room. Upon entering the room, the floor was noted to be covered in urine and Resident # 146 was standing by the bed urinating on the floor. The nurse was notified, and she called the housekeeping immediately. During an interview with Staff G, a Licensed Practical Nurse (LPN) /UnitManager on 03/24/2023 at 11:20 AM; Staff G stated that Resident # 146 urinated on his room floor many times. She encouraged him to call for assistance every time he was going to go to the bathroom, but he continued to do it. The resident had behaviors and there was no way to redirect him. Review of the facility's Infection Prevention and Control Program policy and procedure dated 6/2020, revised on 9/29/2021 revealed in part, Policy: It is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations and national guidelines. The Procedures included, but was not limited to: 1. The facility will establish and maintain an infection prevention and control program under which it: a. Prevents, identifies, reports, investigates, and controls the spread of infections and communicable disease in the facility. b. Conducts surveillance for early detection of infections, clusters/ outbreaks, and reportable diseases and to track and trend surveillance data. c. Decides when and how isolation should be applied to an individual resident. d. Prohibits staff with a communicable infection or disease or infected skin lesions. from direct contact with residents or their food, if direct contact will transmit the disease/infection; and e. Maintains a record of incidents and corrective actions related to infection. prevention and control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 40 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 f. Ensure compliance with state and federal regulations regarding infection control. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 3/24/2023 at 8:02AM, the Infection Preventionist (IP), Registered Nurse stated, I have been the Infection Preventionist for over a year now at this facility. I have done re-education with all nurses on how to clean, disinfect and sanitize the glucometer properly and the right product to clean with. Some of the staff refer to the cleaning products as alcohol instead of Sani-wipes. On 3/22/2023, and 3/24/2023 we started training all our nursing staff on the cleaning, disinfecting, and sanitizing of the glucometers, all our in-house nursing staff have been trained. Our agency nurses receive training over the phone and as they come to the facility for an assignment before they start working. The cleaning product that we are using to clean, sanitize and disinfect the glucometers is an approved product by the manufacturer of the glucometers according to the instructions. The Infection Preventionist reported regarding the residents on transmission-based precautions, the facility has 3 residents on contact precautions for Candida Auris, 1 resident on contact precautions for Disseminated Mycobacterium Intracellular Complex (DMAC) and 3 residents on droplet precautions for Covid-19 precautions/new admission. The rooms that residents on transmission-based precautions are in have the appropriate signage on the door, personal protective equipment by the room for staff to use, and biohazard bins in the room for disposal of PPE. The residents on transmission-based precautions are not on modified contact precautions, anyone that enter these residents' rooms must wear the full personal protective equipment provided (gowns, gloves, face shield, N95 mask) and dispose of used PPE in the biohazard bin in the room prior to exiting. The residents on transmission-based precaution for Candida Auris will be on contact precautions for as long as they are in the facility. The residents on transmission-based precaution for COVID-19 precautions will be on droplet precautions for 10 days. All staff are trained in the correct use of personal protective equipment, Infection control education to the staff at the facility is ongoing and is completed monthly. The Infection Preventionist stated that staff are monitored for compliance regarding wearing personal protective equipment and handwashing by doing random observations of staff while they are actively working with residents on the units. If the observed staff is performing a task incorrectly, corrections and re-education are made immediately. The corrections/re-education is also discussed at our weekly meetings and monthly quality assurance meetings. Residents Affected - Few The facility's approved IJ Removal Plan was verified as completed on 3/24/2023, with the IJ Removal effective on 3/23/2023. The following was verified: On 3/22/2023, the Charge Nurse interceded and reviewed the policy with the Staff H, RN. The glucometers were removed from the cart, cleaned, and disinfected and the drawer for the glucometers was cleaned and disinfected. On 3/22/2023, Staff H was removed from her assignment and the staff agency was notified. On 3/22/2023, the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) checked the carts and confirmed the appropriate disinfectant wipes were available to clean the glucometers. On 3/22/2023, the DON, ADON and Infection Preventionist, began retraining all licensed nurses currently working including agency nurses using the facility policy for cleaning the glucometers and validating the training with return demonstration using a competency compliance audit tool which includes the steps that need to be implemented to reduce the risk for transmission of blood borne pathogens. Only nurses who successfully pass the validation competency will be allowed to work. On 3/22/2023, the DON/ADON reviewed the list of diagnoses of the resident with an order for blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 41 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few glucose monitoring. There was only one resident on the nurse's assignment with orders for blood glucose monitoring. No residents on her assignment were noted with a diagnosis related to blood borne pathogens. An Inservice for the 3:00 PM to 11:00 PM and 11:00PM to 7:00 AM licensed nurses to be conducted by the clinical nursing staff utilizing the facility glucometer cleaning policy and procedure by a return demonstration validation competency. The nurses must successfully complete the competency as a return demonstration of the in service provided prior to beginning the med pass. The licensed nurses were educated to follow manufacturer's guidelines regarding the contact time of the disinfecting product. The licensed nurses will keep the glucometer wet for maximal kill time indicated on the disinfecting agent product label. Glucometers that have been cleaned and disinfected will be placed in a plastic bag and placed in the top drawer of the medication cart. On 3/22/2023, all licensed nurses on the 3:00 PM to 11:00PM shift were re-educated at the beginning of the shift by the Infection Preventionist. All nurses successfully completed their return demonstration competency as validation of the teaching provided. On 3/22/2023, a log for contracted nursing agency staff was created which is to be maintained at the receptionist desk to confirm agency staff scheduled to work has received the contracted staff orientation and has also received education on the facility glucometer cleaning policy and procedure, followed by a return demonstration competency to validate education received. Agency staff who have not received orientation will be educated prior to beginning their shift. On 3/22/2023, an Ad Hoc Quality Assurance meeting was held, members present included the NHA/RM (Nursing Home Administrator/Risk Manager), DON, ADON, Social Services Director, Infection Preventionist, Unit Managers, Activity Director, MDS (Minimum Data Set) Coordinator, Regional Director of Clinical Services, and the alternate Medical Director. The performance improvement plan was approved at the Ad Hoc meeting. On 3/22/2023, the licensed nurses 11:00 PM to 7:00 AM shift were re-educated by the nursing supervisor on the glucometer cleaning policy and return demonstration to validate education received. On 3/23/2023, the licensed nurses on the 7:00 AM to 3:00 AM shift were re-educated by the Infection Preventionist/designee on the glucometer policy followed by a return demonstration competency. The nurse manager/supervisor or designee on each unit will review the daily schedule to ensure all licensed nurses including agency nurses have received glucometer cleaning training and successfully completed the return demonstration competency prior to beginning their med pass. Any clinical nursing staff identified by the nurse manager who has not received the training will be trained prior to beginning their shift. Newly hired clinical nursing staff will receive training during their general orientation. To validate the education received and successful completion of return demonstration competencies is followed the DON, ADON, Infection Preventionist designee will observe licensed nurses including agency nurses cleaning the glucometer to ensure the licensed nurses follow the facility infection control policy. The Infection Preventionist, ADON or designee will make daily rounds and observe infection control practices of the areas listed above to ensure the staff follow the facility infection control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 42 of 43 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 106133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Dade Nursing and Rehabilitation Center 1255 NE 135th Street North Miami, FL 33161 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few guidelines. For staff who fail their observation are to be immediately re-educated and required to complete the training/competency checklist. As of 3/23/2023 44 out of 55 licensed nurses employed have been educated and successfully completed the return demonstration competency validation. Eleven out of 55 licensed nurses were contacted by phone to be educated on the facility glucometer cleaning policy and gave a verbal demonstration over the phone. The nurses who were educated by phone will have a hands-on demonstration conducted prior to beginning their shift. 100% were educated in person or by phone. The facility currently uses 5 agency nurses in which all 5 nurses have been educated on the cleaning policy and successfully completed return demonstration to validate education received. The Infection Preventionist/designee will observe at least 6 nurses cleaning the glucometer each shift daily for 2 weeks, then weekly for 4 then monthly for 2 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 43 of 43