Inspection·January 28, 2026

N0000 INITIAL COMMENTS

N0000 02/28/2026

N0110 SS = D Physical Environment - Safe, Clean, Homelike CFR(s): 400.141(1)(h) FS; 59A-4.122(1) FAC 400.141(1)(h) FS Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 59A-4.122(1) FAC The licensee must provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on observation, interview and record review, the facility failed to ensure the safety of one (Resident #7) out of three vulnerable residents reviewed for falls. As evidenced by during transport from the facility Resident #7 fell in his wheelchair to the floor of the transport vehicle in his wheelchair and sustained a rib fracture. There were 212 residents residing in the facility at the time of the survey. The findings include. Observation of the vehicle involved in the incident was not completed because it was not available on site during the survey. Record review of the Agency for Healthcare Administration Immediate Report submitted 01/21/2026 at

N0110 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 01.21.26, all resident transportation appointments were postponed pending assessment of the facility van. On 01.23.26, all standard retractors and lap and shoulder belts were replaced as a preventative measure. On 01.27.26, a multipoint inspection of the facility van was performed of the vehicle's safety restraints and was found to be fully operational to transport. On 01.28.26, the facility's driver was re-educated on safe resident transportation, proper use of equipment to maintain safety, and compliance with State and Federal laws, with returned demonstration. On 01.28.26, Resident #7 returned to the facility and the resident's plan of care was reviewed and updated. The facility's Transportation policy and procedures were reviewed and updated on 01.29.26 to include that all residents who are being transported in the facility's van must be accompanied by family representative or staff member. On 01.29.26, Unit Clerks involved with the scheduling resident appointments were in-serviced on the updated policy and procedure on transportation. 03/28/2026 Office of Primary Care and Health Systems Management STATE FORM Florida Department of Health PRINTED: 03/12/2026 APPROPRIATE DEFICIENCY)

N0110 Continued from page 1 N0110 Continued from page 1 SS = D 6:30 PM indicated: Type of Incident- Serious Bodily How you will identify other residents having potential Injury. Description of Incident. On 01/21/2026, the to be affected by the same deficient practice and what resident's son informed the nurse supervisor that the corrective action will be taken. resident stated to him that during his transportation No other residents were potentially affected due to all ride to his scheduled oncology appointment, he fell in transportation appointments being suspended pending the van. The resident's son stated that after the assessment of the van. resident was seen and evaluated at his appointment, he What measures will be put in place or what systematic was transferred to the hospital via ambulance where it changes you will make to ensure that the deficient was determined that the resident had sustained a practice does not recur. fracture of the ribs. Review of the nursing progress notes for Resident # 7 A multipoint inspection of the facility van will be dated 01/21/2026 timestamped 07:00 AM documented: completed every three months, and a daily vehicle log Resident left the facility for a medical appointment. will be maintained identifying any vehicle and Resident's vital signs were stable. Respirations even equipment issues, which will be reported immediately to and unlabored, no shortness of breath or distress noted, the Assistant Administrator. The daily vehicle logs resident verbalized no pain or discomfort at the time, will be submitted to the Assistant Administrator skin warm and dry to touch. No signs of hyperglycemia weekly. or hypoglycemia observed. Progress note dated 01/21/2026 timestamped 06:30 PM On 01.28.26, the facility's driver was re-educated on documented: Resident departed the facility at 7:00 PM safe resident transportation, proper use of equipment for a previously scheduled appointment to the hospital to maintain safety, and compliance with State and utilizing facility transportation services. Prior to Federal laws, with returned demonstration. departure, resident was assessed and found to be in On 01.29.26, Unit Clerks involved with the scheduling stable condition, with vital signs within normal limits of resident appointments were in-serviced on the and no complaints of pain, discomfort, dizziness, or updated policy and procedure on transportation, which distress noted at the time. At 4:30 PM, the resident's included ensuring that all residents will be son arrived at the facility and reported that he (Staff A) accompanied by a staff member or family representative that the resident had fallen inside the vehicle. during all trips. According to the resident son, the resident had How the corrective action(s) will be monitored to been informed by the Transportation Driver (Staff A) ensure the deficient practice will not recur, i.e. what that the resident had fallen inside the vehicle. quality assurance program will be put in place. According to the resident son, the resident had For the next three months, the Assistant Administrator initially transported to one hospital where an X-ray will observe the facility's driver demonstrate all revealed pneumothorax, afterwards the resident was safety protocols, twice weekly, for 100% compliance. subsequently transferred to another hospital where he The Assistant Administrator will report monthly the was admitted for further medical management and findings and corrective actions to the Quality monitoring. Upon receiving this information, the Assurance and Performance Improvement Committee which facility supervisor and physician were promptly will determine if any additional actions are needed to notified of the incident and the resident's current [blank page] hospitalized status. The oncoming nurse will be [blank page] notified to follow-up. [blank page] Review of Resident #7 medical records revealed the [blank page] resident was initially admitted to the facility on [blank page] 06/16/2024, Readmitted on 01/07/2026. Clinical [blank page] diagnoses included but not limited [blank page] to:1/28/2026-Traumatic Pneumothorax, subsequent [blank page] encounter, 1/28/2026-Traumatic Hemothorax, subsequent [blank page] encounter, 1/28/2026-Multiple fracture of wings, right [blank page] side, encounter for fracture with routine healing. [blank page] Florida Department of Health PRINTED: 03/12/2026 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX PREFIX TAG TAG APPROPRIATE DEFICIENCY) COMPLETION DATE

N0110 N0110 SS = D Continued from page 2 Improve services and procedures, or if policies and procedures need to be updated. If any deficient practices are noted, the committee will make recommendations to achieve compliance. If any deficient practices are noted, additional in-services will be provided. Continued from page 2 This plan of correction does not constitute an Chronic Obstructive Pulmonary Disease (COPD) with admission that the deficiencies alleged did in fact (acute) exacerbation, Acute and Chronic Respiratory exist. The plan of correction is filed as evidence of Failure with Hypoxia and Hypercapnia. Emphysema. the facility's desire to comply with the requirements Malignant Neoplasms of upper lobe, right bronchus or and to continue to provide high quality resident care. lung. Shortness of Breath. Resident #7 was discharged on 01/21/2026. Review of the Physician's Orders Sheet for January 2026 revealed Resident #7 had orders that included but not limited to: Oxygen via nasal cannula at 2 liters per minute (lpm) as needed for oxygen saturation (sp02) less than 92% related to Acute and Chronic Respiratory Failure. Albuterol 2.5 mg/0.5 ml via nebulizer with Hypertonic Sodium 10 milligrams (mg) one (1) tablet by mouth related to COPD. Theophylline 300 mg extended release- one (1) tablet by mouth every 12 hours for COPD. Gel cushion when in wheelchair for comfort every shift. Record review of Resident #7 's Discharge Return Anticipated Minimum Data Set (MDS) dated 01/21/26 revealed the resident is Cognitively intact. The section for Functional Abilities documented the resident is dependent on care, is always incontinent of bowel and bladder. Health Conditions documented the resident had one fall with major injury. The section for medications documented the resident is receiving Antidepressant, Hypnotic, Antiplatelet, Hypoglycemic. Special Treatments and Procedures documented the resident is receiving oxygen therapy. Record review of Resident #7 's Care Plans Reference Date 01/28/2026 revealed: Resident/family/caregiver were educated on fall reduction strategies. Patient will ask for assistance when assistance is needed. Patient will assist staff to maintain a safe environment. Patient will comply with staff instructions Patient will keep bed in low position. Patient will keep environment clutter free. Resident will use call light when assistance is needed. Review resident's medication regimen as needed. Skilled therapy evaluations and treatments as ordered by physician. Staff to assist resident with wheelchair safety to reduce risk of fall and injury every shift. Interview on 01/28/2026 at 4:36 PM, the facility's Transportation Driver (Staff A) stated: "On 01/21/26 in the morning on my way to drop the resident (Resident #7) from the facility to a medical appointment close to [local hospital] the following events occurred. - I transported the resident from his room at the facility and took him to the transport vehicle at the entrance Florida Department of Health 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

N0110 SS = D Continued from page 3 of the facility, I placed the resident in his wheelchair, on the vehicle lift and raised him up into the vehicle, I secured the wheelchair with four (4) straps to the wheelchair, grounded to the floor of the vehicle, and a belt around his waist secured to the wheelchair, I began driving the resident to his appointment, when I was approximately a block away, I heard a noise at the back of the vehicle, I looked back into the vehicle and saw the resident lying on his left side on the floor of the vehicle, still in his wheelchair. I stopped the vehicle, went to the back where the resident was, I unhooked the seatbelt around the resident's waist, left the resident on the floor, placed the wheelchair in an upright position, and then placed the resident back into the wheelchair and secured the resident the same way I did at the beginning of the trip. Once the resident was secured, I continued to the appointment that was approximately a minute away. When I got to the appointment destination I met the resident's son, I told the resident's son what happened, he spoke to his father, the resident stated he was ok and the son told me it was ok to leave, then I left. I found out later that the resident's son called the facility and let someone at the facility know what happened. After I left the appointment, I came back to the facility. When I returned to the facility I did not report what had happened with the resident in the vehicle. On my way home that day the facility called and told me the resident's son reported to them what had happened and I needed to make a report. The next day I came to the facility to make a report of the events that happened with the resident the day before, after I made my report, I was told I was on suspension pending the results of the investigation. Currently I am still on suspension. I was only supposed to drop the resident off to his appointment, the resident's son usually spends the day with him after his appointments and bring him back to the facility afterwards." During an interview on 1/28/2026 at 6:27 PM, the Risk Manager, Assistant Administrator (NHA)/Abuse Coordinator revealed that on 01/21/2026 at approximately at 6:30 PM Resident #7's son came to the facility and spoke to Registered Nurse Supervisor (Staff B)he reported that his dad was at the hospital and on that morning he met the transport driver (Staff A) at his father's medical appointment and the transport driver (Staff A) told him his father had fallen in the vehicle. He spoke with his father, and he was feeling ok at the time and did not have any pain. He continued with his father's medical appointment, during the appointment his father's oxygen saturation STATE FORM Florida Department of Health PRINTED: 03/12/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156

N0110 Continued from page 4 N0110 SS = D went down to 89, but he did not complain of any pain. The staff at the medical appointment called the ambulance and sent the resident to the hospital. His father was later transferred to another hospital, his father was told his father had a rib fracture and pneumothorax. The resident was then sent from one hospital to another for full evaluation. The son repeated that he did not notice any injury to his father, and he did not think his father had (Staff A) did anything wrong. On 01/21/26 after the son spoke with the Registered Nurse (RN) (Staff B), Risk Manager NH/Abuse Coordinator, telephone interviews were conducted with the IRN Supervisor (Staff B), the resident's assigned Licensed Practical Nurse (Staff C) and the Transport Driver (Staff A) who worked on 01/21/2026. The Registered Nurse NHA and DON exactly what the resident's son told her as mentioned above. The residents assigned Licensed Practical Nurse (Staff C) on 01/21/2026 stated he saw the resident's son in the facility later that day and the resident's son told him that his father fell in the transport vehicle on his way to his appointment. The Transport Driver (Staff A) reported at 8:01 AM on 01/21/2026 he picked the resident up from the facility to take him to his appointment as usual. Prior to leaving the facility, he placed the resident in the vehicle, applying the four straps from the floor to each locking rail where the wheelchair was positioned. Applied the seatbelt across the waist of the resident, then attached to the floor. When he was approximately a minute to the appointment destination, he heard a noise and when he looked back in the vehicle, he saw [Resident #7] falling backwards to the left side. He stopped the vehicle and went to the resident immediately, asked the resident how he was doing. [Resident #7] stated he was not in any pain, he did not notice any blood or injuries. He then took off all the straps to reposition the resident back to a safety position. He then proceeded to the medical appointment with the resident, took the resident out of the vehicle to the medical appointment and waited for the resident's son. When the resident's son arrived, he notified his father about the fall in the vehicle, the son checked his father's body and asked him if he was ok. [Resident #7] stated he was ok and did not complain of any pain. [Resident #7's] son told the transport driver it was ok for him to leave, and he continued with his father into the building to his medical appointment. On 01/23/2026 we interviewed [Resident #7] via telephone at the hospital, he stated that he was feeling better, the driver did position his wheelchair properly with the Four (4) straps and the seatbelt to his waist. The drive to the appointment was approximately 30 minutes. Florida Department of Health 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

N0110 SS = D Continued from page 5 as they were getting close to the medical appointment, the vehicle came to a stop, and he fell backwards in his wheelchair. The driver came to help him immediately and asked him if he had any pain to which his answer was no, the driver then repositioned him in the vehicle and they continued to the appointment where he met his son. During the appointment he started to have shortness of breath and the staff at the appointment sent him to hospital for further evaluation...it was not the Transport Driver's (Staff A) fault, he has gone to many appointments with the particular (Staff A) and has not had any safety issues with him. We interviewed three residents that were transported by the driver in the past and they stated they did not have any safety concerns/issues with the Transport Driver (Staff A). "We tested the Transport Driver (Staff A) within 24 hours of the event, the result was negative for any drug use, reviewed his employee file, his level 2 background screening was up to date. Transport Driver (Staff A) was evaluated and received training from the previous driver, we have never had any issues or concerns related to his driving or safety of the residents he transports. In addition, the Transport Driver (Staff A) has a log that he keeps regarding any issues (maintenance or repair) needing to be completed on the vehicle and notifies administration of any repairs needed. On 01/27/2026 to maintain safety of the vehicle we contacted the company he used for the facility's vehicle maintenance, a Certified Mechanic completed a thorough inspection of the vehicle to include the seatbelt buckles, harness, safety tie downs, as well as the floor mounted locking rails. The Certified Mechanic concluded the equipment was safe and fully operational. We replaced the 4 single straps, lap and shoulder belts as an extra measure. The four (4) single straps, lap and shoulder belt in the vehicle is used to keep the residents safe during transport. We filed a timely, immediate and five-day Agency for Healthcare Administration report, we are still in the process of determining if this event qualifies as an adverse incident and needs to be reported. Despite all safety measures being in place the resident still suffered a fall on 01/21/2026 during transport. The facility had no control of the event taking place. To prevent any future incidents from happening the transport vehicle was inspected and serviced to include new safety equipment." Review of facility policy and procedure titled "Safety and Supervision of Residents" revision date 10/2025 indicate: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent STATE FORM Florida Department of Health

N0110 SS = D Continued from page 6 accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process; Risk Management/Quality Assurance Committee (RM/QA) reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Class III N0110 PUBLIC HEALTH SERVICE RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156

F0000 INITIAL COMMENTS F0000 02/28/2026

F0689 SS = D Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) $483.25(d) Accidents. The facility must ensure that - $483.25(d)(1) The resident environment remains as free of accident hazards as possible; and $483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT IS NOT MET as evidenced by: Based on observation, interview and record review, the facility failed to ensure the safety of one (Resident #7) out of three vulnerable residents reviewed for falls. As evidenced by during transport from the facility Resident #7 fell to the floor of the transport vehicle in his wheelchair and sustained a rib fracture. There were 212 residents residing in the facility at the time of the survey. The findings include. Observation of the vehicle involved in the incident was not completed because it was not available on site during the survey. Record review of the Agency for Healthcare Administration Immediate Report submitted 01/21/2026 at 6:30 PM indicated: Type of Incident- Serious Bodily Injury; Description of Incident: On 01/21/2026, the F0689 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 01.21.26, all resident transportation appointments were postponed pending assessment of the facility van. On 01.23.26, all standard retractors and lap and shoulder belts were replaced as a preventative measure. On 01.27.26, a multipoint inspection of the facility van was performed of the vehicle's safety restraints and was found to be fully operational to transport. On 01.28.26, the facility's driver was re-educated on safe resident transportation, proper use of equipment to maintain safety, and compliance with State and Federal laws, with returned demonstration. On 01.28.26, Resident #7 returned to the facility and the resident's plan of care was reviewed and updated. The facility's Transportation policy and procedures were reviewed and updated on 01.29.26 to include that all residents who are being transported in the facility's van must be accompanied by family representative or staff member. On 01.29.26, Unit Clerks involved with the scheduling resident appointments were in-serviced on the updated policy and procedure on transportation. 02/28/2026 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX COMPLETION TAG DATE

F0689 SS = D CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Continued from page 1 F0689 resident's son informed the nurse supervisor that the Continued from page 1 resident stated to him that during his transportation ride to his scheduled oncology appointment, he fell in the van. The resident's son stated that after the resident was seen and evaluated at his appointment, he was transferred to the hospital via ambulance where it was determined that the resident had sustained a fracture of the ribs. Review of the nursing progress notes for Resident # 7 dated 01/21/2026 timestamped 07:00 AM documented: Resident left the facility for a medical appointment at the 7:00 AM with facility transportation. Resident's vital signs were stable. Respirations even and unlabored, no shortness of breath or distress noted. Resident verbalized no pain or discomfort at the time, skin warm and dry to touch. No signs of hyperglycemia or hypoglycemia observed. Progress note dated 01/21/2026 timestamped 06:30 PM documented: Resident departed the facility at 7:00 AM for a previously scheduled appointment at the hospital utilizing facility transportation services. Prior to departure, resident was assessed and found to be in stable condition, with vital signs within normal limits and no complaints of pain, discomfort, dizziness, or distress noted at the time. At 4:30 PM, the resident's son arrived at the facility and reported that he had been informed by the Transportation Driver (Staff A) that the resident had fallen inside the vehicle. According to the resident son, the resident was initially transported to one hospital where an X-ray revealed pneumothorax, afterwards the resident was subsequently transferred to another hospital where he was admitted for further medical management and monitoring. Upon receiving this information, the facility supervisor and physician were promptly notified of the incident and the resident's current hospitalization status. The oncoming nurse will be notified to follow-up. Review of Resident #7 medical records revealed the resident was initially admitted to the facility on 06/16/2024, Readmitted on 01/07/2026. Clinical diagnoses included but not limited to: 1/28/2026-Traumatic Pneumothorax, subsequent encounter, 01/28/2026-Traumatic Hemothorax, subsequent encounter, 1/28/2026-Multiple fracture of wings, right side, encounter for fracture with routine healing. Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation, Acute and Chronic Respiratory Failure with Hypoxia and Hypercapnia Emphysema. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. No other residents were potentially affected due to all transportation appointments being suspended pending assessment of the van. What measures will be put in place or what systematic changes will be made to ensure that the deficient practice does not recur. A multipoint inspection of the facility van will be completed every three months, and a daily vehicle log will be maintained identifying any vehicle and equipment issues, which will be reported immediately to the Assistant Administrator. The daily vehicle logs will be submitted to the Assistant Administrator weekly. On 01.28.26, the facility's driver was re-educated on safe resident transportation, proper use of equipment to maintain safety, and compliance with State and Federal laws, with returned demonstration. On 01.29.26, Unit Clerks involved in the scheduling of resident appointments were in-serviced on the updated policy and procedure on transportation, which included ensuring that all residents will be accompanied by a staff member or family representative during all trips. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put in place. For the next three months, the Assistant Administrator will observe the facility's driver demonstrate all safety protocols, twice weekly, for 100% compliance. The Assistant Administrator will report monthly the findings and corrective actions to the Quality Assurance and Performance Improvement Committee which will determine if any additional actions are needed to improve services and procedures, or if policies and 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0689 SS = D Continued from page 2 Malignant Neoplasm of upper lobe, right bronchus or lung. Shortness of Breath. Resident #7 was discharged on 01/21/2026. Review of the Physician's Orders Sheet for January 2026 revealed Resident #7 had orders that included but not limited to: Oxygen via nasal cannula at 2 liters per minute (l/min) as needed for oxygen saturation (sp02) less than 92% related to Acute and Chronic Respiratory Failure with Hypercapnia. Montelukast Sodium 10 milligrams (mg) one (1) tablet by mouth daily for COPD. Theophylline 300 mg extended release- one (1) tablet with mouth every 12 hours for COPD. Gel cushion when in wheelchair for comfort every shift. Record review of Resident #7's Discharge Return Anticipated Minimum Data Set (MDS) dated 01/21/26 Revealed: The resident is Cognitive intact; Functional Abilities section documented the resident is dependent on care, always incontinent of bowel and bladder. Health Conditions documented the resident had one fall with major injury. Section for Medications documented the resident is receiving Antidepressant, Hypnotic, Antiplatelet, Hypoglycemic. Special Treatments and Procedures documented the resident is receiving oxygen therapy. Record review of Resident #7's Care Plans Reference Date 01/28/2026 revealed: Resident/family/caregiver were educated on fall reduction strategies. Patient will ask for assistance when assistance is needed. Patient will assist staff to maintain a safe environment. Patient will comply with staff instructions Patient will keep bed in low position. Instructions Patient will keep environment clutter free. Resident will use call light when assistance is needed. Review resident's medication regimen as needed. Skilled therapy evaluations and treatments as ordered by physician. Staff to assist resident with wheelchair safety to reduce risk of fall and injury every shift. Interview on 01/28/2026 at 4:36 PM, the facility's Transportation Driver (Staff A) stated: "On 01/21/26 in the morning on my way to drop the resident [Resident #7] from the facility to a medical appointment close to [local hospital] the following events occurred. -I transported the resident from his room at the facility and took him to the transport vehicle at the entrance of the facility, I placed the resident in his wheelchair on the vehicle lift and raised him up into

F0689 Continued from page 2 procedures need to be updated. If any deficient practices are noted, the committee will make recommendations to achieve compliance. If any deficient practices are noted, additional in-services will be provided. This plan of correction does not constitute an admission that the deficiencies alleged did in fact exist. The plan of correction is filed as evidence of the facility's desire to comply with the requirements and to continue to provide high quality resident care. 106094 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0689 SS = D

F0689 Continued from page 3 I secured the wheelchair with four (4) straps to the vehicle, grounded to the floor of the vehicle, and a belt around his waist secured to the wheelchair. I began driving the resident to his appointment, when I was approximately a block away, I heard a noise at the back of the vehicle, I looked back into the vehicle and saw the resident lying on his left side on the floor of the vehicle, still in his wheelchair. I stopped the vehicle, went to the back where the resident was, unhooked the seatbelt around the resident's waist, left him unhooked on the floor, placed the wheelchair in an upright position, and then placed the resident back into the wheelchair and secured the resident the same way that I had at the beginning of the trip. Once the resident was secured, I continued to the appointment that was approximately a minute away. When I got to the appointment destination I met the resident's son, I told the resident's son what happened, he spoke with his father, the resident stated he was ok and the son told me it was ok to leave, then I left. I found out later that the resident's son called the facility and let someone at the facility know what happened. After I left the appointment, I came back to the facility. When I returned to the facility I did not report what had happened with the resident in the vehicle. On my way home that day the facility called and told me the resident's son reported to them what had happened and I needed to make a report. The next day I came to the facility with the resident the day before, after I made my report, I was told that I was on suspension pending the results of the investigation. Currently I am still on suspension. Currently, I am only supposed to drop the resident off to his appointment, the resident's son usually spends the day with him after his appointments and bring him back to the facility afterwards. During an interview on 1/28/2026 at 6:27 PM, the Risk Manager, Assistant Administrator (NHA)/Abuse Coordinator revealed that on 01/21/2026 at approximately 6:30 PM Resident #7's son came to the facility and spoke to Registered Nurse Supervisor (Staff B)-he reported that his dad was at the hospital and on that morning he met the transport driver (Staff A) at his father's medical appointment and the transport driver (Staff A) told him his father had fallen in the vehicle. He spoke with his father, and he was feeling ok at the time and did not have any pain. He continued with his father's medical appointment, during the appointment his father's oxygen saturation went down to 89, but he did not complain of any pain. The staff at the medical appointment called the ambulance and sent the resident to the hospital, his 106094 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0689 SS = D Continued from page 4 father was later transferred to another hospital. At the hospital he was told his father had a rib fracture and pneumothorax. The resident was then sent from one hospital to another for full evaluation. The son repeated that he did not notice any injury to his father, and he did not think the Transport Driver (Staff A) did anything wrong. On 01/21/2026 after the son spoke with the Registered Nurse (RN) Supervisor (Staff B), Risk Manager Assistant NHA/Abuse Coordinator, telephone interviews were conducted with the RN Supervisor (Staff B), the resident's assigned Licensed Practical Nurse (Staff B), and the Transport Driver (Staff A) who worked on 01/21/2026. The Registered Nurse supervisor (Staff B) told the Risk Manager, Assistant NHA and DON exactly what the resident's son told her as mentioned above. The residents assigned Licensed Practical Nurse (Staff C) on 01/21/2026 stated he saw the resident's son in the facility later that day and the resident's son told him that his father fell in the transport vehicle on his way to his appointment. The Transport Driver (Staff A) reported at 8:01 AM on 01/21/2026 he picked the resident up from the facility to take him to his appointment as usual. Prior to leaving the facility, he placed the resident in the vehicle, applying the four straps from the floor to each locking rail where the wheelchair was positioned. Applied the seatbelt across the waist of the resident, then attached to the floor. When he was approximately a minute to the appointment destination, he heard a noise and when he looked backwards to the vehicle, he saw [Resident #7] falling backwards to the left side. He stopped the vehicle and went to the resident immediately, asked him how he was doing. [Resident #7] stated he was not in any pain, he did not notice any blood or injuries. He then took off all the straps to reposition the resident back to a safety position. He then proceeded to the medical appointment with the resident, took the resident out of the vehicle at the medical appointment and waited for the resident's son. When the resident's son arrived, he notified the son about the fall in the vehicle, the son checked his father's body and asked him if he was ok. [Resident #7] stated he was ok and did not complain of any pain. [Resident #7's] son told the transport driver it was ok for him to leave, and he continued with his father into the building to his medical appointment. On 01/23/2026, he interviewed (Resident #7) via telephone, at the hospital, he stated that (Resident #7) via telephone, the driver did position his wheelchair properly with the four (4) straps and the seatbelt to his waist. The drive to the appointment was approximately 30 minutes, as they were getting close to the medical appointment, the vehicle came to a stop, and he fell backwards in his wheelchair. The driver came to help him immediately

F0689 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

F0689 Continued from page 5 SS = D and asked him if he had any pain to which his answer was no, the driver then repositioned him in the vehicle and they continued to the appointment where he met his son. During the appointment he started to have shortness of breath and the staff at the appointment sent him to hospital for further evaluation...it was not the Transport Driver's (Staff A) fault, and he has gone to many appointments with the particular (Staff A) and has not had any safety issues with him. We interviewed three residents that were transported by the driver in the past and they stated they did not have any safety concerns/issues with the Transport Driver (Staff A). We tested the Transport Driver (Staff A) within 24 hours of the event, the result was negative for any drug use, reviewed his employee file, his level 2 background screening was up to date, Transport Driver (Staff A) was evaluated and received training from the previous driver, we have not had any issues or concerns related to his driving or safety of the residents he transports. In addition, the Transport Driver (Staff A) has a log that he keeps regarding any issues (maintenance or repair) needing to be completed on the vehicle and notifies administration of any repairs needed. On 01/27/2026 to maintain safety of the vehicle we contacted the company we used for the facility's vehicle maintenance, a Certified Mechanic completed a thorough inspection of the vehicle to include the seatbelt buckles, harness, safety tie downs, as well as the floor mounted locking rails. The Certified Mechanic concluded the equipment was safe and fully operational. We replaced the 4 single straps, lap and shoulder belts as an extra measure. The four (4) single straps, lap and shoulder belt in the vehicle is used to keep the residents safe during transport. We filed a timely, immediate and five-day Agency for Healthcare Administration report, we are still in the process of determining if this event qualifies as an adverse incident and needs to be reported. Despite all safety measures being in place the resident still suffered a fall on 01/21/2026 during transport. The facility had no control of the event taking place. To prevent any future incidents from happening the transport vehicle was inspected and serviced to include new safety equipment.

F0689 Review of facility policy and procedure titled "Safety and Supervision of Residents" revision date 10/2025 indicate: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 106094 01/28/2026 RIVIERA HEALTH RESORT 6901 YUMURI STREET, CORAL GABLES, Florida, 33156 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0689 SS = D Continued from page 6 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process; Risk Management/Quality Assurance Committee (RM/QA) reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization.

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