Health inspection·September 20, 2023

F 0626 Level of Harm - Actual harm Residents Affected - Few Review of the Facility assessment dated [DATE] documented: The facility may accept residents with, or residents may develop the following common disease, conditions, physical and cognitive disabilities or combinations of conditions that require complex medical care and management for the following: Heart/Circulatory System (Hypertension, Atherosclerotic Heart Disease), Neurological System (Hemiplegia, Cerebral Infarction), Genitourinary System (Chronic Kidney Disease), Respiratory System (Shortness of Breath); If it is determined that the facility is able to meet the needs of the resident, the individual will be admitted . Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #2 documented, the resident's Mental Status (BIMS) Summary Score was not scored, indicating severe cognitive impairment, required total dependence with one person physical assist for ADLs (activities of daily living) and the resident did not expect to be discharged to the community and will not be returning back to the community. Review of the Physician's Orders Sheet (POS) dated [DATE] through [DATE] for Resident #2 documented, the resident received the following: Oxygen at 2 liters via N/C (nasal cannula) every 8 hours PRN (as needed) for shortness of breath, Trazodone HCL (hydrochloride) 50mg (milligram) tab 1 tab (tablet) PO (by mouth) HS (at night) for insomnia and Plavix 75mg tab 1 tab PO in the morning for atherosclerotic heart disease. The resident had doctor's order for the following: Transfer resident to [ ] local hospital via 911, Diagnosis: Respiratory Distress (dated [DATE]) and Transfer Resident to [ ] local hospital for Diagnosis: Seizure (dated [DATE]). Review of the Resident's #2's discharge care plan dated [DATE] documented the plans were for the resident to remain in the facility. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #2 documented, the notice was sent with the resident to the hospital on [DATE] with an effective date of [DATE]. The location to which the resident is to be transferred or discharged was a local hospital. The Reason for Discharge or Transfer: Your needs cannot be met in this facility. Okay to transfer resident to [ ] local hospital emergency room via emergency services for evaluation of seizure. The form was not signed nor dated by the resident and the resident was notified verbally. Review of the discharge summary progress note for Resident #2 dated [DATE] at 23:51 documented: Around 11:30 PM, resident noted with seizures. Two episodes of seizures noted. Call placed to [ ] local emergency services. Order received to transfer resident to [ ] local hospital North for active seizures. On [DATE] at 9:38 AM, interview with the Social Services Director. She stated, I am responsible for discharge back to the community ALF (assisted living facility), ILF (independent living facility), home or transfer to another facility. Social services is responsible for discharge care planning. I am not in charge of this discharge because he went to the hospital. His discharge care plan was for the resident to remain in the facility dated [DATE]. On [DATE] at 11:09 AM, interview with the facility's Marketing Director. She stated, My responsibility is as a liaison between the facility and the hospital. I only do clinical. I send the paperwork and the facility let me know if they can take the patient. The resident does not have legal status. The resident had been here for a long time. He came during (Coronavirus Disease) COVID and was working on his legal status and never got it done. He was not discharged back here because we were trying to get documents such as ID (identification) to prove legal status. If the patient doesn't have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 2 of 10 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 09/20/2023 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 0626 Level of Harm - Actual harm Residents Affected - Few legal status, he can't come back because there is no payor source. Recently we obtained a social security number but that is not enough. The resident is still in the hospital. [ ] is the Director of Case Management at a [ ] local hospital. We had a conversation with [ ] Director of Case Management since the resident had been in the hospital and we told him we could bring him back with a letter LOA (letter of absence of hospital billing/Letter of Agreement), but [ ], Director of Case Management refused. Last week I spoke to the [ ] Director of Case Management and he wants me to bring back the resident with [ ] health insurance that will cover only 20%. [ ] is in Corporate and she oversees all the facilities for admissions. Record review with the Marketing Director of text messages starting on [DATE] with the Director of Case Management at the local hospital documented the facility agreed to take back the resident with an LOA but the Director of Case Management at the local hospital refused to provide the LOA. When the Marketing Director was asked for clinical documentation between the Director of Case Management at a local hospital, she revealed that the only communication documented was via text messages. On [DATE] at 12:16 PM via telephone, interview with the Regional Director of Marketing and Admissions. She stated, He was able to be readmitted but we requested that he be under the contract with [ ] local hospital. We have a special contract with [ ] local hospital and it entails that they can place a resident who doesn't have insurance, they can do an LOA. Then [ ] the local hospital pays for their stay. I remember this case, I have been in correspondence with [ ] who is at [ ] the local hospital. [ ] said she would look into it. She said [ ] Director of Case Management never called her and asked about the LOA. But I spoke to [ ] and she said she would get back to me. [ ] Director of Case Management at [ ] the local hospital never gave [ ] the information. If they would have said the patient was not eligible for LOA, we would have taken the patient back. We would take the patient back today. On [DATE] at 12:57 PM, during interview with the Admissions Director. She stated, My responsibility is once the Marking Director gets the referral, we take the referral and send it the Director of Nursing to review it. Once we get the approval we then go and run the financial and get an authorization from the insurance. The resident went to the hospital and the case manager from the hospital and the marketing director communicated with text messages that we needed a letter of agreement (LOA). She was the one that communicated with him. We will take the patient back but with a LOA. First time he came he had insurance. He had no insurance when he was here. We took him back when he went out on [DATE] because he went to [ ] another local hospital and we don't have an agreement with them. On [DATE] at 1:10 PM, during interview with the Director of Nursing (DON)(This is the facility's previous DON). She stated, When a resident is transferred to the hospital, we send the labs, list of medications, transfer paper, the bed hold is given and a copy uploaded in the system. On [DATE], around 11:15 resident was noted with labored breathing and congestion. A breathing treatment was given and a call was placed to the medical doctor. A new order was received to transfer resident to a local hospital via emergency services with a diagnosis of respiratory distress. Emergency services arrived shortly after and transferred the resident to the hospital. On [DATE], the resident was re-admitted to the facility. On [DATE], around 11:30 PM, the resident was noted with seizures. Two episodes of seizures were noted. A call was placed to emergency services. An order was received to transfer the resident to a local hospital with a diagnosis of active seizures. The resident did not return to the facility. On [DATE] at 1:38 PM, during interview with the Administrator. She stated, I know he was discharged to [ ] a local hospital. [ ] Director of Case Management from [ ] local hospital said that he would be returning with a contract. We have a [ ] local hospital contract for residents that don't have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 3 of 10 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 09/20/2023 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 0626 Level of Harm - Actual harm status. The person at [ ] a local hospital wasn't complying with [ ] Director of Case Management who was at [ ] local hospital main campus, which is their internal issue. We are prepared to take him back. We called [ ] local hospital today to tell them we would take the resident back but he was discharged . He was discharged on [DATE] but I do not know where he went. Residents Affected - Few Review of the hospital records for Resident #2 dated [DATE] to [DATE] revealed the local hospital listed over fifty nursing homes contacted between two counties to find placement for the resident after the facility refused to readmit the resident. They couldn't get another nursing home to take the resident until they found someone to become the residents health care proxy. The hospital was able to find the residents daughter and she became his health care proxy and they were able to get another nursing home to accept the resident. Based on the hospital's Social Services notes dated [DATE], the resident had an active discharge order on [DATE]. The hospital was providing the resident PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy), services the facility could have provided. On [DATE] at 12:04 PM via telephone, interview with the Director of Clinical Resource Department for a local hospital. He stated, Through [ ] a clinical program we send all the clinical information and the referrals. The initial referral goes through [ ] a clinical program. I did communicate with [ ] the Marketing Director through text messages but the communication was mainly through [ ] a clinical program. The issue that I had with this patient, was that this patient was living there for more than two years. I don't know how they were getting paid before and the patient was admitted to [ ] a local hospital and we tried to admit him back and they refused. The answer from the facility for not taking the patient back was the Medicare was inactive and they didn't want to pay for the resident. We reached out to our finance team about the Medicare and because of the resident's status, the residency was not renewed. If the legal status is going to expire, they should have had a social worker renew their status. What they wanted to do was a letter of agreement. For the letter of agreement, [ ] the local hospital pays out of the state taxes. We will pay for the admission to the facility. The patient had [ ] Medicaid. I did not want to give them a letter of agreement because the resident had a payor source which was [ ] Medicaid. We had a lot of back and forth about this patient. Medicare was still active in their system and they felt, they shouldn't have to pay for him. There reason for not taking the resident back was because it was not enough from [ ] Medicaid to cover the skill care for long term for the resident. [ ] Medicaid would not give us authorization. They gave us authorization thirty days later and then I contacted [ ] Marketing Director and the facility refused to take the resident back. We always try to push to send the patient back to where they come from because their belongings are there. We found the daughter in another [ ] state, and she thought her father was deceased . She came to the hospital and now is the proxy for her father. We contacted numerous nursing homes to find placement for the patient but they declined to admit the patient. The patient went to [ ] nursing home. They have an email from [ ] Medicaid. On [DATE] at 11:26 AM, interview and record review with the current DON. He stated, I have been the new DON for three weeks. The Transfer and Discharge Requirements Policy & Procedure dated [DATE] given earlier was revised today to include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. The same policy and procedure received on [DATE] at 9:37 AM, for the Transfer and Discharge Requirements Policy & Procedure dated [DATE] obtained from the Administrator did not include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. On [DATE] at 11:39 AM, interview with the Administrator. She stated, In the Admission, Transfer and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 4 of 10 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 09/20/2023 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 0626 Level of Harm - Actual harm Residents Affected - Few Discharge Policy and Procedure, I expect the staff to follow the policy. Basically, what the policy says. If the patient is discharged to the hospital they should be readmitted to the facility. The facility did not complete the paperwork for a facility-initiated discharge, because we did intend to take the resident back. I was not involved in the discharge process, because he went out for a clinical reason, and I was aware of him going out to the hospital. [ ] Staff A, LPN (Licensed Practical Nurse) and the ADON (Assistant Director of Nursing) signed the nursing home transfer and discharge notice on [DATE]. A notice of discharge was not sent to the resident at the hospital while hospitalized . The resident's payor source was Medicare Part A, B and D. Medicaid was pending. Subsequent interview and record review of admissions and discharges from [DATE] to [DATE] on [DATE] at 1:46 PM with the Administrator. She stated, One hundred and twenty eight residents were sent to the hospital and allowed to return during the time period, that the resident [Resident #2] was not allowed to return. He was the only one that didn't return back. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 5 of 10 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 09/20/2023 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility's administration failed to implement, provide and ensure an effective and efficient discharge process was in place for one resident (Resident #2) out of three sampled residents who were discharged . Resident #2 was transferred to the hospital on [DATE], and was not permitted to return to the facility he had lived in since [DATE]. Resident #2 was in the hospital from [DATE] to [DATE]. The resident was ready for discharge from the hospital on [DATE] and was not allowed to return to the facility due to not having a payor source. The deficient practice enabled the facility to initiate a discharge while resident #2 was in the hospital and did not permit the resident to return to his home which created psychosocial harm to resident #2. Residents Affected - Few The findings included: Record review of the facility's Administration Policy and Procedure (issued 3/2021) documented the following: It is the policy of the facility to provide appropriate Administration in accordance to State and Federal regulations. Procedure: 1) The facility shall comply with all applicable standards and rules of the agency and shall be under the administrative direction and charge of a licensed administrator, 4) Facility Management is responsible to assist the administrator in overseeing the day to day operations of all departments in the facility, 6) Responsible to monitor each department's activities and communications to elevate performance per facility policies and legal requirements, 11) Develop and maintain written policy and procedures that govern day to day operations of the facility, 14) Ensure resident care is provided in accordance with facility policies and meets professional standards of care and 15) Attend the quality assurance committee, safety meetings as well as other oversight functions to ensure quality resident care. Review of the Job Description for the Nursing Home Administrator documented: The Administrator is responsible for developing, managing and supervising the overall functions of the facility in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Director of Nursing documented: The Director of Nursing is responsible for planning, organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Director of Social Services documented: The Director of Social Services is to plan, organize, develop and direct the overall operation of the facility social services department in accordance with current federal, state and local standards, guidelines and regulations and as directed by the Administrator. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Marketing Director documented: The Marketing Director is responsible for assisting the admissions team in managing referral sources, community outreach, admissions process and marketing programs for the facility, guiding and strategizing a marketing program for services that assures strong relationships with hospitals and payor satisfaction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 6 of 10 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 09/20/2023 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 0835 Level of Harm - Actual harm Residents Affected - Few Review of the Job Description for the Admissions Coordinator documented: The Admissions Coordinator is responsible for obtaining required information and admit residents in an efficient manner in accordance with established facility policies and procedures and as directed by your supervisor. Review of the Job Description for the Bookkeeper/Business Office documented: The Bookkeeper/Business Office is responsible for assisting in the day to day bookkeeping functions of the facility in accordance with current acceptable accounting practices and as directed by the Administrator, Director of Finance or accountant. Review of the Job Description for the Public Relations/Marketing Director known as the Regional Director of Marketing and Admissions documented: The Public Relations/Marketing Director is responsible to plan, develop, organize, implement, evaluate and direct the facility public relations and marketing programs and activities in order to maintain the resident census. Review of the Demographic Face Sheet for Resident #2 documented, the resident was admitted on [DATE] with a diagnoses of cerebral infarction, atherosclerotic heart disease, chronic kidney disease, hypertension, insomnia, hemiplegia and shortness of breath. The resident was discharged on [DATE] to the hospital, readmitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Review of the Facility assessment dated [DATE] documented: The facility may accept residents with, or residents may develop the following common disease, conditions, physical and cognitive disabilities or combinations of conditions that require complex medical care and management for the following: Heart/Circulatory System (Hypertension, Atherosclerotic Heart Disease), Neurological System (Hemiplegia, Cerebral Infarction), Genitourinary System (Chronic Kidney Disease), Respiratory System (Shortness of Breath); If it is determined that the facility is able to meet the needs of the resident, the individual will be admitted . Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #2 documented, the resident's Mental Status (BIMS) Summary Score was not scored, indicating severe cognitive impairment, required total dependence with one person physical assist for ADLs (activities of daily living) and the resident did not expect to be discharged to the community and will not be returning back to the community. Review of the Physician's Orders Sheet (POS) dated [DATE] through [DATE] for Resident #2 documented, the resident received the following: Oxygen at 2 liters via N/C (nasal cannula) every 8 hours PRN (as needed) for shortness of breath, Trazodone HCL (hydrochloride) 50mg (milligram) tab 1 tab (tablet) PO (by mouth) HS (at night) for insomnia and Plavix 75mg tab 1 tab PO in the morning for atherosclerotic heart disease. The resident had doctor's order for the following: Transfer resident to [ ] local hospital via 911, Diagnosis: Respiratory Distress (dated [DATE]) and Transfer Resident to [ ] local hospital for Diagnosis: Seizure (dated [DATE]). Review of the Resident's #2's discharge care plan dated [DATE] documented the plans were for the resident to remain in the facility. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #2 documented, the notice was sent with the resident to the hospital on [DATE] with an effective date of [DATE]. The location to which the resident is to be transferred or discharged was a local hospital. The Reason for Discharge or Transfer: Your needs cannot be met in this facility. Okay to transfer resident to [ ] local hospital emergency room via emergency services for evaluation of seizure. The form was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 7 of 10 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 09/20/2023 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 0835 signed nor dated by the resident and the resident was notified verbally. Level of Harm - Actual harm Review of the discharge summary progress note for Resident #2 dated [DATE] at 23:51 documented: Around 11:30 PM, resident noted with seizures. Two episodes of seizures noted. Call placed to [ ] local emergency services. Order received to transfer resident to [ ] local hospital North for active seizures. Residents Affected - Few On [DATE] at 9:38 AM, interview with the Social Services Director. She stated, I am responsible for discharge back to the community ALF (assisted living facility), ILF (independent living facility), home or transfer to another facility. Social services is responsible for discharge care planning. I am not in charge of this discharge because he went to the hospital. His discharge care plan was for the resident to remain in the facility dated [DATE]. On [DATE] at 11:09 AM, interview with the facility's Marketing Director. She stated, My responsibility is as a liaison between the facility and the hospital. I only do clinical. I send the paperwork and the facility let me know if they can take the patient. The resident does not have legal status. The resident had been here for a long time. He came during (Coronavirus Disease) COVID and was working on his legal status and never got it done. He was not discharged back here because we were trying to get documents such as ID (identification) to prove legal status. If the patient doesn't have legal status, he can't come back because there is no payor source. Recently we obtained a social security number but that is not enough. The resident is still in the hospital. [ ] is the Director of Case Management at a [ ] local hospital. We had a conversation with [ ] Director of Case Management since the resident had been in the hospital and we told him we could bring him back with a letter LOA (letter of absence of hospital billing/Letter of Agreement), but [ ], Director of Case Management refused. Last week I spoke to the [ ] Director of Case Management and he wants me to bring back the resident with [ ] health insurance that will cover only 20%. [ ] is in Corporate and she oversees all the facilities for admissions. Record review with the Marketing Director of text messages starting on [DATE] with the Director of Case Management at the local hospital documented the facility agreed to take back the resident with an LOA but the Director of Case Management at the local hospital refused to provide the LOA. When the Marketing Director was asked for clinical documentation between the Director of Case Management at a local hospital, she revealed that the only communication documented was via text messages. On [DATE] at 12:16 PM via telephone, interview with the Regional Director of Marketing and Admissions. She stated, He was able to be readmitted but we requested that he be under the contract with [ ] local hospital. We have a special contract with [ ] local hospital and it entails that they can place a resident who doesn't have insurance, they can do an LOA. Then [ ] the local hospital pays for their stay. I remember this case, I have been in correspondence with [ ] who is at [ ] the local hospital. [ ] said she would look into it. She said [ ] Director of Case Management never called her and asked about the LOA. But I spoke to [ ] and she said she would get back to me. [ ] Director of Case Management at [ ] the local hospital never gave [ ] the information. If they would have said the patient was not eligible for LOA, we would have taken the patient back. We would take the patient back today. On [DATE] at 12:57 PM, during interview with the Admissions Director. She stated, My responsibility is once the Marking Director gets the referral, we take the referral and send it the Director of Nursing to review it. Once we get the approval we then go and run the financial and get an authorization from the insurance. The resident went to the hospital and the case manager from the hospital and the marketing director communicated with text messages that we needed a letter of agreement (LOA). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 8 of 10 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 09/20/2023 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 0835 Level of Harm - Actual harm Residents Affected - Few She was the one that communicated with him. We will take the patient back but with a LOA. First time he came he had insurance. He had no insurance when he was here. We took him back when he went out on [DATE] because he went to [ ] another local hospital and we don't have an agreement with them. On [DATE] at 1:10 PM, during interview with the Director of Nursing (DON)(This is the facility's former DON). She stated, When a resident is transferred to the hospital, we send the labs, list of medications, transfer paper, the bed hold is given and a copy uploaded in the system. On [DATE], around 11:15 resident was noted with labored breathing and congestion. A breathing treatment was given and a call was placed to the medical doctor. A new order was received to transfer resident to a local hospital via emergency services with a diagnosis of respiratory distress. Emergency services arrived shortly after and transferred the resident to the hospital. On [DATE], the resident was re-admitted to the facility. On [DATE], around 11:30 PM, the resident was noted with seizures. Two episodes of seizures were noted. A call was placed to emergency services. An order was received to transfer the resident to a local hospital with a diagnosis of active seizures. The resident did not return to the facility. On [DATE] at 1:38 PM, during interview with the Administrator. She stated, I know he was discharged to [ ] a local hospital. [ ] Director of Case Management from [ ] local hospital said that he would be returning with a contract. We have a [ ] local hospital contract for residents that don't have status. The person at [ ] a local hospital wasn't complying with [ ] Director of Case Management who was at [ ] local hospital main campus, which is their internal issue. We are prepared to take him back. We called [ ] local hospital today to tell them we would take the resident back but he was discharged . He was discharged on [DATE] but I do not know where he went. Review of the hospital records for Resident #2 dated [DATE] to [DATE] revealed the local hospital listed over fifty nursing homes contacted between two counties to find placement for the resident after the facility refused to readmit the resident. They couldn't get another nursing home to take the resident until they found someone to become the residents health care proxy. The hospital was able to find the residents daughter and she became his health care proxy and they were able to get another nursing home to accept the resident. Based on the hospital's Social Services notes dated [DATE], the resident had an active discharge order on [DATE]. The hospital was providing the resident PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy), services the facility could have provided. On [DATE] at 12:04 PM via telephone, interview with the Director of Clinical Resource Department for a local hospital. He stated, Through [ ] a clinical program we send all the clinical information and the referrals. The initial referral goes through [ ] a clinical program. I did communicate with [ ] the Marketing Director through text messages but the communication was mainly through [ ] a clinical program. The issue that I had with this patient, was that this patient was living there for more than two years. I don't know how they were getting paid before and the patient was admitted to [ ] a local hospital and we tried to admit him back and they refused. The answer from the facility for not taking the patient back was the Medicare was inactive and they didn't want to pay for the resident. We reached out to our finance team about the Medicare and because of the resident's status, the residency was not renewed. If the legal status is going to expire, they should have had a social worker renew their status. What they wanted to do was a letter of agreement. For the letter of agreement, [ ] the local hospital pays out of the state taxes. We will pay for the admission to the facility. The patient had [ ] Medicaid. I did not want to give them a letter of agreement because the resident had a payor source which was [ ] Medicaid. We had a lot of back and forth about this patient. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 9 of 10 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 09/20/2023 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 0835 Level of Harm - Actual harm Residents Affected - Few Medicare was still active in their system and they felt, they shouldn't have to pay for him. There reason for not taking the resident back was because it was not enough from [ ] Medicaid to cover the skill care for long term for the resident. [ ] Medicaid would not give us authorization. They gave us authorization thirty days later and then I contacted [ ] Marketing Director and the facility refused to take the resident back. We always try to push to send the patient back to where they come from because their belongings are there. We found the daughter in another [ ] state, and she thought her father was deceased . She came to the hospital and now is the proxy for her father. We contacted numerous nursing homes to find placement for the patient but they declined to admit the patient. The patient went to [ ] nursing home. They have an email from [ ] Medicaid. On [DATE] at 11:26 AM, interview and record review with the current DON. He stated, I have been the new DON for three weeks. The Transfer and Discharge Requirements Policy & Procedure dated [DATE] given earlier was revised today to include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. The same policy and procedure received on [DATE] at 9:37 AM, for the Transfer and Discharge Requirements Policy & Procedure dated [DATE] obtained from the Administrator did not include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. On [DATE] at 11:39 AM, interview with the Administrator. She stated, In the Admission, Transfer and Discharge Policy and Procedure, I expect the staff to follow the policy. Basically, what the policy says. If the patient is discharged to the hospital they should be readmitted to the facility. The facility did not complete the paperwork for a facility-initiated discharge, because we did intend to take the resident back. I was not involved in the discharge process, because he went out for a clinical reason, and I was aware of him going out to the hospital. [ ] Staff A, LPN (Licensed Practical Nurse) and the ADON (Assistant Director of Nursing) signed the nursing home transfer and discharge notice on [DATE]. A notice of discharge was not sent to the resident at the hospital while hospitalized . The resident's payor source was Medicare Part A, B and D. Medicaid was pending. On [DATE] at 11:54 AM, interview with the Business Office Manager. She stated, I have been in this position for a year. My responsibilities are on a day to day to update the census, manage resident trust accounts, Medicaid pending doing the applications and documents needed, update payor trees such as primary, secondary payor sources and request authorization for long term care here in the facility. I collect the documents and [ ] our Medicaid Coordinator was doing the application for Medicaid. I remember [ ] Medicaid Coordinator saying that he had immigration issues and was pending Medicaid for a while until we came up with the charity case. His primary payor source was charity care. Basically, our company came up with this payor source for residents that have issues with legal status. Prior to us coming up with charity care, he was Medicaid pending. At one time he had Medicare. On the face sheet there was a Medicare number for the resident. He was Medicaid pending. We didn't use the Medicare number was because it was ineligible effective [DATE]. The charity case started [DATE]. When he was initially admitted to our facility he was admitted under [ ] Medicaid [ ] which was basically for therapy services. We had four residents, under [NAME] Care and we currently have only three. Subsequent interview and record review of admissions and discharges from [DATE] to [DATE] on [DATE] at 1:46 PM with the Administrator. She stated, One hundred and twenty eight residents were sent to the hospital and allowed to return during the time period, that the resident [Resident #2] was not allowed to return. He was the only one that didn't return back. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 10 of 10