Inspection·June 30, 2025

F 0689 On 6/30/2025 at 2:58 PM, interview with the Social Services Director. He stated, This is the second time with the coffee maker. The first time was an actual coffee maker and the staff removed it. 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 2 of 7 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 06/30/2025 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a well-balanced diet to meet special dietary needs for one diabetic (Resident #1) out of three residents sampled. There were 40 diabetic residents out of the 211 residents present in the facility at the time of the survey. The findings included: Record review of the facility's policy titled Nutrition and Hydration (revised 6/2021) documented: Policy-Residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being; Policy Explanation and Compliance Guidelines: 1) The facility will: a) Provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment, b) Recognize, evaluate and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration, c) Provide a therapeutic diet taking into account the resident's clinical condition and preferences and d) Resident's diet order is communicated to the dietary department by completing a dietary communication slip and 2) Based on the resident's comprehensive assessment, the facility will ensure each resident: c) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. Observation and interview of Resident #1 on 6/30/25 at 7:43 AM, revealed the resident sitting in a chair in his room and received his breakfast tray. The breakfast tray consisted of: Boiled egg (1), Oatmeal (1 bowl), Toast (2 slices), Regular Sugar (3 packets), Regular grape jelly (1 packet), Coffee (1 cup). The tray did not include a meat, a choice of Vitamin C juice, sugar substitutes and sugar-free jelly. The resident revealed via a Spanish translator that he eats what his roommate tells him to eat on the food tray because he is diabetic. He doesn't use the regular sugar or regular jelly. They don't send him a diabetic sugar or jelly on his food tray. Photographic evidence submitted. Review of the Breakfast Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet; Boiled Egg no shell or scrambled, Sausage or ham. To be served: Choice of Vitamin C juice (6 ounces), Oatmeal or Frosted Flakes Cereal (1/2 cup or ¾ cup), Scrambled eggs, Crispy bacon Strip (1 strip), Biscuit (1 each), Jelly (1 packet), Margarine (1 each) Whole milk (8 ounces), Coffee/Hot tea (6 ounces), Sugar, Pepper (1 each). Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, hypertension, hemiplegia, protein-calorie malnutrition and hyperlipidemia. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 11, indicating mild cognitive impairment and able to make his needs known. The resident required partial to moderate to substantial/maximal assistance for ADLs (activities daily living) and supervision or touching assistance for eating. A therapeutic diet was prescribed for the resident. Review of the Physician's Order Sheets (POS) dated May 2025 and June 2025 for Resident #1 documented the resident was on a LCS (Low Concentrated Sweets), NAS (No Added Salt), Regular texture and Thin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 3 of 7 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 06/30/2025 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 0800 Level of Harm - Minimal harm or potential for actual harm consistency. The resident receives Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml (milliliters) inject 4 unit subcutaneously before meals related to diabetes mellitus with hyperglycemia, Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml inject as per sliding scale subcutaneously before meals for hyperglycemia related to diabetes mellitus with hyperglycemia and Insulin Glargine Solution 100 unit/ml inject 6 unit subcutaneously every 12 hours related to diabetes mellitus. Residents Affected - Few Review of the Nutrition care plan (written 2/05/2025) for Resident #1 documented the following: Focus: Resident is at risk for nutritional and or hydration deficits as evidenced by hyperglycemia and hemiplegia; Goal: Resident will show no s/s (signs and symptoms) of dehydration (dry skin, dry cracked lips, concentrated urine, increased confusion, abnormal labs that may indicate dehydration) thru NRD (next review date) x (times) 90D (90 days); Interventions: LCS, NAS diet, Regular texture and Thin consistency; Offer meal substitute as needed/requested; Review/counsel on prescribed diet, including any negative outcomes of non-adherence as applicable. A second observation of Resident #1 on 6/30/25 at 12:14 PM, revealed the resident sitting in a chair in his room, eating lunch. The lunch tray consisted of: Black beans, Rice, Chopped Baked Chicken, Unfrosted Banana Cake and Orange Drink. The tray did not include navy bean soup, buttered carrots or any vegetable, coffee or tea and sugar substitutes. Review of the Lunch Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet. To be served: Navy Bean Soup (6 oz. ladle), Baked Chicken (3 ounces protein), Rice/Arroz (1/2 cup), Buttered Carrots (#8 scoop = ½ cup), Banana Cake (1 piece), Coffee/Tea (6 ounces), Sugar, Pepper (1 each). Review of the facility's Weekly Four Cycle Menu LCS/NAS diet documented the following: 1) Week 3 on Monday, 6/30/2025 residents received at breakfast: Choice of Vitamin C juice, Oatmeal or Frosted Flakes Cereal, Scrambled eggs, Crispy bacon Strip, Biscuit, Diet Jelly, Margarine, Whole milk, Coffee/Hot tea, Sugar Substitute and Pepper and 2) Week 3 on Monday, 6/30/2025 residents received at lunch: Navy Bean Soup, Baked Chicken, Rice/Arroz, Buttered Carrots, Unfrosted Banana Cake, Coffee/Tea, Sugar Substitute and Pepper. Review of Food and Beverage Preferences for Resident #1 dated 6/09/25 documented the resident disliked pancakes, desserts and sweets of any kind and no rice. On 6/30/2025 at 3:22 PM, interview with the Diet Technician (DT). She stated, LCS/NAS Regular diet with thin consistency. He is a diabetic. Yes, the meal ticket says LCS/NAS diet. We have [sugar substitute] and have diabetic jelly for diabetics. On 6/30/2025 at 3:46 PM, interview with the Dietary Manager. He stated, He had oatmeal, boiled egg, coffee, with regular sugar and regular jelly. I have diabetic jelly and [sugar substitute] for diabetics. He should not have gotten the regular sugar and jelly for breakfast. For lunch, I used substitute for navy bean soup which was black bean soup and for buttered carrots substituted peas. He should have had peas on his plate. Review of the Facility Assessment, updated 2/29/2024, date reviewed with QAPI Committee 2/29/2024 documented the facility has a diverse patient population and the Nutrition department provided individualized dietary requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 4 of 7 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 06/30/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that menus were followed for nutritional adequacy to meet special dietary needs for one diabetic (Resident #1) out of three residents sampled. There were 40 diabetic residents out of the 211 residents present in the facility at the time of the survey. The findings included: Observation and interview of Resident #1 on 6/30/25 at 7:43 AM, revealed the resident sitting in a chair in his room and received his breakfast tray. The breakfast tray consisted of: Boiled egg (1), Oatmeal (1 bowl), Toast (2 slices), Regular Sugar (3 packets), Regular grape jelly (1 packet), Coffee (1 cup). The tray did not include a meat, a choice of Vitamin C juice, sugar substitutes and sugar-free jelly. The resident revealed via a Spanish translator that he eats what his roommate tells him to eat on the food tray because he is diabetic. He doesn't use the regular sugar or regular jelly. They don't send him a diabetic sugar or jelly on his food tray. Photographic evidence submitted. Review of the Breakfast Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet; Boiled Egg No shell or scrambled, Sausage or ham. To be served: Choice of Vitamin C juice (6 ounces), Oatmeal or Frosted Flakes Cereal (1/2 cup or ¾ cup), Scrambled eggs, Crispy bacon Strip (1 strip), Biscuit (1 each), Jelly (1 packet), Margarine (1 each) Whole milk (8 ounces), Coffee/Hot tea (6 ounces), Sugar, Pepper (1 each). Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, hypertension, hemiplegia, protein-calorie malnutrition and hyperlipidemia. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 11, indicating mild cognitive impairment and able to make his needs known. The resident required partial to moderate to substantial/maximal assistance for ADLs (activities daily living) and supervision or touching assistance for eating. A therapeutic diet was prescribed for the resident. Review of the Physician's Order Sheets (POS) dated May 2025 and June 2025 for Resident #1 documented the resident was on a LCS (Low Concentrated Sweets), NAS (No Added Salt), Regular texture and Thin consistency. The resident receives Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml (milliliters) inject 4 unit subcutaneously before meals related to diabetes mellitus with hyperglycemia, Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml inject as per sliding scale subcutaneously before meals for hyperglycemia related to diabetes mellitus with hyperglycemia and Insulin Glargine Solution 100 unit/ml inject 6 unit subcutaneously every 12 hours related to diabetes mellitus. Review of the Nutrition care plan (written 2/05/2025) for Resident #1 documented the following: Focus: Resident is at risk for nutritional and or hydration deficits as evidenced by hyperglycemia and hemiplegia; Goal: Resident will show no s/s (signs and symptoms) of dehydration (dry skin, dry cracked lips, concentrated urine, increased confusion, abnormal labs that may indicate dehydration) thru NRD (next review date) x (times) 90D (90 days); Interventions: LCS, NAS diet, Regular texture and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 5 of 7 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 06/30/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Thin consistency; Offer meal substitute as needed/requested; Review/counsel on prescribed diet, including any negative outcomes of non-adherence as applicable. A second observation of Resident #1 on 6/30/25 at 12:14 PM, revealed the resident sitting in a chair in his room, eating lunch. The lunch tray consisted of: Black beans, Rice, Chopped Baked Chicken, Unfrosted Banana Cake and Orange Drink. The tray did not include navy bean soup, buttered carrots or any vegetable, coffee or tea and sugar substitutes. Review of the Lunch Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet. To be served: Navy Bean Soup (6 oz. ladle), Baked Chicken (3 ounces protein), Rice/Arroz (1/2 cup), Buttered Carrots (#8 scoop = ½ cup), Banana Cake (1 piece), Coffee/Tea (6 ounces), Sugar, Pepper (1 each). Review of the facility's Weekly Four Cycle Menu LCS/NAS diet documented the following: 1) Week 3 on Monday, 6/30/2025 residents received at breakfast: Choice of Vitamin C juice, Oatmeal or Frosted Flakes Cereal, Scrambled eggs, Crispy bacon Strip, Biscuit, Diet Jelly, Margarine, Whole milk, Coffee/Hot tea, Sugar Substitute and Pepper and 2) Week 3 on Monday, 6/30/2025 residents received at lunch: Navy Bean Soup, Baked Chicken, Rice/Arroz, Buttered Carrots, Unfrosted Banana Cake, Coffee/Tea, Sugar Substitute and Pepper. Review of Food and Beverage Preferences for Resident #1 dated 6/09/25 documented the resident disliked pancakes, desserts and sweets of any kind and no rice. On 6/30/2025 at 3:22 PM, interview with the Diet Technician (DT). She stated, LCS/NAS Regular diet with thin consistency. He is a diabetic. Yes, the meal ticket says LCS/NAS diet. We have [sugar substitute] and have diabetic jelly for diabetics. On 6/30/2025 at 3:46 PM, interview with the Dietary Manager. He stated, He had oatmeal, boiled egg, coffee, with regular sugar and regular jelly. I have diabetic jelly and [sugar substitute] for diabetics. He should not have gotten the regular sugar and jelly for breakfast. For lunch, I used substitute for navy bean soup which was black bean soup and for buttered carrots substituted peas. He should have had peas on his plate. Review of the Menu Substitution Log dated 6/30/25 documented the lunch planned menu items were substituted. The planned menu item was Buttered Carrots and was substituted for peas and the planned menu item for dessert was Banana Cake and was substituted for Yellow cake, no frosting. Review of the Facility Assessment, updated 2/29/2024, date reviewed with QAPI Committee 2/29/2024 documented the facility has a diverse patient population and the Nutrition department provided individualized dietary requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 6 of 7 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 06/30/2025 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 - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F689 Accidents Hazards and F803 Menus Meet Resident Needs and Followed. These deficient practices have the potential to affect 211 residents residing in the facility at the time of the survey. The findings included: Record review of Quality Assurance and Performance Improvement (QAPI) policy and procedure (issue date June 2021). The purpose of the committees is to review and analyze facility related data, evaluate improvement plans effectiveness and direct appropriate actions for the facility response. Systems failures and/or in-depth analysis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s) of the systems failure and implementation of corrective actions. Review of the facility's survey history revealed, during a recertification survey with exit dated August 1, 2024, F689 Accidents Hazards and F803 Menus Meet Resident Needs and Followed were cited. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 4/22/25, 5/20/25 and 6/24/25: documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. Interview with the Administrator on 06/30/2025 at 5:07 PM. She revealed the QAPI (Quality Assurance and Performance Improvement) meetings are held on the third Tuesday of each month or as needed. She stated that QAPI committee members are Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Risk Manager, Social Services Director, Dietary Manager, Maintenance Director, Human Resources, Activity Director, Restorative, Housekeeping/Laundry Supervisor, Registered Dietitian, Business Office Manager, Unit Managers and Pharmacy. She stated, The purpose of the QAPI committee is to ensure all departments are in compliance with policies and procedures and regulatory statures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106133 If continuation sheet Page 7 of 7