Inspection·December 8, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to aid during dining for 1 of 1 sampled resident reviewed for Activities of Daily Livings (ADLs) (Resident #111). Residents Affected - Few The findings included: In an observation conducted on 12/06/22 at 8:00 AM, Resident #111 was noted eating her breakfast tray with no staff in the room. At 8:10 AM, Resident #111 was still eating with no assistance from staff and consumed about 50 percent of her breakfast meal. In an observation conducted on 12/06/22 at 12:04 PM, Resident #111 was in the room with the lunch tray at her bedside, and no staff was noted. At 12:15 PM, she ate 10% of her lunch meal, and no staff member was in the room to assist her with her lunch. Continued observation at 12:20 PM showed that she ate 25% of her meal with no staff in the room. (photographic evidence obtained) A chart review showed that Resident #111 was admitted on [DATE] with diagnoses of Dysphagia, Dementia, and Anemia. The MDS (Minimum Data Set) dated 09/05/22 showed that under section C, for Brief Interview of Mental Status (BIMS), Resident #111 had a score of 02 out of 15, which indicate the resident is severely cognitively impaired. Under section G for eating, Resident #111 needs extensive assistance from one person assist. The Speech Therapy Screening Form dated 11/23/22 showed that Resident #111 for on enteral feeding for her main source of nutrition and hydration because of her history of poor intake. It further showed that Resident #111 has poor safety judgment and is to be followed up as needed. In an interview conducted on 12/07/22 at 10:55 AM with Staff C, Staff D, and Staff E, MDS's Coordinators stated that Resident #111 was coded under Section G for eating as needing extensive assistance with one person's assistance. When asked what it meant, they stated that Resident #111 needs someone in the room physically to make sure that Resident #111 is eating. It is not only encouragement to eat but assisting with the meals as well. They also said that they get their information about the residents by looking at the Certified Nursing Assistants' documents, Speech Therapy Assessments, and the Electronic System. In an interview conducted on 12/07/22 at 11:00 AM, Staff A, Certified Nursing Assistant, stated that Resident #111, at times, needs help with her meals. She further revealed that the resdenteats 100% of her meals. The care plan dated 09/07/22 showed that Resident #111 is at risk for an alteration in nutrition and hydration. It further showed to provide cues/encouragement during meals and provide hands-on assistance with eating at meals and as needed. A review of the CNA's (Certified Nursing Assistants) intake of meals from 11/24/22 to 12/07/22 showed that Resident #111 needed the following: 1 documented at independent-no help or staff oversight at any time, five recorded at supervision - oversight, encouragement, or cueing, six reported at limited assistance Resident highly involved in the activity; staff provides guided maneuvering of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 2 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few limbs or other non-weight-bearing assistance, eight documented at extensive assistance - Resident engaged in the activity, staff provide weight-bearing support, and 20 recorded at total dependence - full staff performance. A review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, revised in March 2018, showed that the following: Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). In an interview conducted on 12/08/22 at 12:30 PM, with the facility's Administrator, she was informed of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 3 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure proper use of splints per physician's order for 2 of 3 residents reviewed for splints (Resident #74 and 122). The findings included: 1) During the initial tour of the facility conducted on 12/05/22 at 9:40 AM, the surveyor noted Resident #74 was wearing splints on both of her hands while lying in bed. Clinical records revealed Resident #74 was admitted to the facility on [DATE]. Resident #74 had a medical history significant for Parkinson's disease, fibromyalgia, depression, anxiety, dementia, and contractures of her hands and ankles. A Quarterly Minimum Data Set (MDS) was done on 09/20/22. This MDS documented Resident #74 had a Brief Interview of Mental Status (BIMS) score of 5, which indicates she had severe cognitive impairment. This MDS also documented Resident #74 required extensive assistance from staff for all activities of daily living. Review of Resident #74's Care Plans revealed there was a care plan in place regarding the contractures and use of splints. Review of Resident #74's physician orders revealed there were orders in place regarding placing splints on her hands and ankles after morning cares and removing the splints before evening cares. There was also an order written on 11/15/22 for Resident #74 to be placed on restorative nursing services. Review of Resident #74's notes revealed there were no notes written regarding Resident #74 refusing to wear or removing splints. Additional observations conducted on 12/06/22, 12/07/22, and 12/08/22 revealed Resident #74 in bed but not wearing her splints. Instead, the ankle splints were observed in the wheelchair and the hands splints were observed on the table under the window in her room. An interview was conducted on 12/08/22 at 10:08 AM with Staff F, Unit Manager. She stated it is the responsibility of the restorative staff to place the splints on the residents and that the nursing staff is supposed to check each resident, based on physician's orders to ensure the splints are being used properly. 2) During the initial tour of the facility conducted on 12/05/22 at 9:45 AM, the surveyor noted Resident #122 was lying in bed and there were splints in a bag on the table under the window in her room. Clinical records revealed Resident #122 was admitted to the facility on [DATE]. Resident #122 had a medical history significant for a traumatic brain injury, diabetes, falls, depression, and contractures of her hands. Review of a Quarterly Minimum Data Set (MDS) dated [DATE]. This MDS documented Resident #122 had a Brief Interview of Mental Status (BIMS) score of 3, which indicates she had severe cognitive impairment. This MDS also documented Resident #122 required extensive assistance from staff for all activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 4 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0688 Level of Harm - Minimal harm or potential for actual harm Review of Resident #122's Care Plans revealed there were care plans in place regarding a decrease in range of motion, but not for the use of splints. Review of Resident #122's physician orders revealed there was an order in place regarding the use of a splint for her left hand due to decrease in range of motion. Residents Affected - Few Review of Resident #122's notes revealed there were no notes written regarding Resident #122 refusing to wear or removing splints. Additional observations conducted on 12/06/22, 12/07/22, and 12/08/22 revealed Resident #122 in bed or in her chair but not wearing her splints. Instead, the hands splints were observed on the table under the window in her room. An interview was conducted on 12/08/22 at 10:08 AM with Staff F, Unit Manager. She stated it is the responsibility of the restorative staff to place the splints on the residents and that the nursing staff is supposed to check each resident, based on physician's orders to ensure the splints are being used properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 5 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow tube feeding orders for 1 out of 7 sampled residents reviewed for tube feeding (resident #58). The findings included: A review of the facility ' s policy titled Enteral Tube Feeding via Continuous Pump, revised in March 2115, showed to position the head of the bed at 30-45 degrees for feeding unless medically contradicted. It further showed to check the label on the enteral formula against the physician's order. A review of the Physician's orders for Resident #58 revealed a Physician's order dated 07/25/22 for tube feeding Osmolite 1.5 (formulary type) at 60 milliliters (ml) per hour for 20 hours via peg tube, held from 8:00 AM to 1:00 PM. Another order dated 06/18/22 to elevate the Head of the bed at least 30-45 degrees while feeding is in progress. In an observation conducted on 12/05/22 at 9:15 AM, Resident #58 was noted in bed. Closer observation showed a tube feeding that was on hold with Osmolite 1.5 at 60 ml an hour and was at the 700 ml mark out of a 1000 ml bottle. Further review showed that the tube feeding bottle was started on 12/05/22 at 12:00 PM. According to the above Physician's orders, the tube feeding should have been at the 520 ml mark out of the 1000 ml capacity bottle. (photographic evidence obtained) In an observation conducted on 12/06/22 at 7:50 AM, Resident #58 was noted in bed. Closer observation showed that the tube feeding was running at 60 ml an hour, and the tube feeding bottle was started on 12/06/22 at 5:00 AM. The tube feeding was noted at the 1000 ml level out of the 1000 ml capacity bottle. Continued observation showed Resident #58 utterly flat on the bed with Staff A, a Certified Nursing Assistant (CNA), providing morning care while the tube feeding was still running. (photographic evidence obtained) A review of the chart showed that Resident #58 was admitted on [DATE] with diagnoses of Parkinson's disease and unspecific severe protein-calorie malnutrition. Review of the Care Plan dated 11/03/22 showed to keep Resident #58's Head elevated at least 30 degrees while tube feeding is infusing and to administer tube feeding formula and flushes as ordered. Progress noted completed on 11/23/22 by the facility's Registered Dietitian revealed that Resident #58 is tolerating her tube feeding well and that the current order provides her protein and calorie needs with Osmolite 1.5 at 60 ml an hour times 20 hours. In an interview conducted on 12/07/22 at 12:36 PM with the facility's Clinical Dietitian, stated on the observation that was conducted on 12/06/22 at 7:50 AM, Resident #58 should have received around 180 ml of a formulary as per the Physician's order. When told of the morning care that was provided by Staff A, without stopping the tube feeding first, she acknowledged the risk for aspiration. In an interview conducted on 12/07/22 at 3:03 PM with Staff B, the Registered Nurse stated that when morning care is provided to the residents, the Certified Nurse Assistant is supposed to call her before to turn off the tube feeding before starting care. She further acknowledged that Staff A did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 6 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0693 not call her to stop the tube feeding before providing care. 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: 686123 If continuation sheet Page 7 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow Physician's orders and failed to update dialysis care plan for discontinued fluid restrictions for 1 out of resident reviewed for dialysis (Resident #47). Residents Affected - Few The findings included: Review of the facility's policy titled Policy and Procedure: Fluid Restrictions dated 08/07/20, included the following: Fluid restrictions may be utilized to assist in controlling body fluid balance, when a resident's clinical condition warrants. Fluid is only restricted when clinically necessary, and for a limited time, when possible, to preserve resident quality of life. A specific physician's order for the amount of fluids to be provided in a 24-hour period is required. When an order is received for fluid restriction, the dietary manager or dietician confers with the nursing department to determine how much fluid each department is to provide. This is based on the number of medications ordered, as well as the total fluid volume permitted. The Food Service Manager or Dietician visits the resident to obtain preferred fluid information, to make the restriction as acceptable as possible. This is entered into the computer so that the specific fluid amounts are printed on the resident's tray cards. The need for fluid restriction is reviewed periodically by the physician, dietician, and nursing staff. When at all possible, this restriction is liberalized or discontinued, to promote optimal compliance and the highest practicable quality of life. Fluid restrictions are care planned by the interdisciplinary team. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, included the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs developed and implemented for each resident. The comprehensive, person-centered care plan will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents 'conditions change. The Interdisciplinary Team must review and update the care plan: a) When there has been significant change in the resident's condition; b) When the desired outcome is not met; c) When the resident has been readmitted to the facility from a hospital stay; and d) At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Review of the facility's policy titled Standards and Guidelines (SG): Hemodialysis with a revised date of 12/2017 included: Standard: It will be the standard of this facility to provide the necessary care and services to those residents receiving hemodialysis while a resident at the facility. Guidelines: If the resident has orders for fluid restriction, they should be clarified as to which shift provides which amount of fluid per shift between nursing and dietary services. The resident will be reviewed by the Interdisciplinary Team (IDT) after admission to determine appropriate orders care plans are addressed with appropriate interventions in place. Record review for Resident #47 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Unspecified Protein-Calorie Malnutrition, Extrarenal Uremia, End Stage Renal Disease, Essential (Primary) Hypertension, and Fluid Overload Unspecified. Review of Section C for cognitive pattern of the Minimum Data Set (MDS) dated [DATE] indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 8 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0698 Level of Harm - Minimal harm or potential for actual harm Resident #47 had a Brief Interview for Mental Status of 6, which indicated that she was severely cognitively impaired. Review of Section G for functional status of the MDS dated [DATE] documented that Resident #47 had a bed mobility, transfer, dressing, toilet use, and personal hygiene all had a self-performance of extensive assistance with support of one person assist, eating had a self-performance of limited assistance with support of one person assist. Residents Affected - Few Review of Physician's Orders for Resident #47 dated 11/29/21 for Fluid Restriction: 1200 ml/day (mililiters per day). Dietary to provide 720 ml: Breakfast-360 Lunch-240, Dinner-120 Nursing: Day shift - 240 ml Night shift - 240 ml. Exclude supplements from restriction every shift was discontinued on 03/17/22. Review of Physician's Orders for Resident #47 dated 07/05/22 for renal diet, regular texture, thin consistency, pureed Meats, and vegetables, per patient request. Maintain aspirations precautions. Review of Physician's Orders for Resident #47 dated 12/10/21 for dialysis (Monday, Wednesday, Friday) chair time 1:00 PM to 4:30 PM, pick up time 12:15 PM. On 12/06/22 a review of the Care Plan for Resident #47 initiated on 11/29/21 with a focus on the resident has potential for complications related to hemodialysis for treatment of End Stage Renal Disease (ESRD). Shunt site is located: (left upper chest) receives dialysis on Monday, Wednesday, and Friday. Goal was for the resident to remain free from complications related to hemodialysis thru the next review date. Interventions included: Maintain fluid restrictions as ordered; observe for compliance. Complete dialysis communication tool on dialysis days and review upon return from dialysis. Review of the Nutrition Risk Evaluation for Resident #47 dated 11/28/22 included: Fluid needs (in ml/day): 1174-1467. Review of the Nutrition Risk Evaluation for Resident #47 dated 08/30/22 included: Fluid needs (in ml/day): 1180-1475. Review of the Nutrition Risk Evaluation for Resident #47 dated 08/23/22 included: Fluid needs (in ml/day): 1180-1475. Review of the Nutrition Risk Evaluation for Resident #47 dated 05/30/22 included: Fluid needs (in ml/day): 1200. Review of the Dialysis Communication Forms for Resident #47 dated 11/23/22, 11/09/22, 11/04/22, 11/02/22, 10/28/22 all included: under the follow up needed prior to next treatment: fluid restrictions. Review of the Dietary progress note dated 12/07/22 included: Hemodialysis (HD) follow-up: Per Dialysis Center Communication (12/5/22), dry current weight= 126.9 pounds (#). No significant weight changes x 30/90/180 days. Resident with varied oral (PO) intake but tolerating diet well. Case discussed with HD RD on monthly basis. As per nephrologist resident has no need for fluid restriction. Recommend continue current dietary interventions as ordered. Care Plan to be updated as needed (PRN). Review of the Dietary progress note dated 11/15/2022 included: HD follow-up: Per Dialysis Center Communication (10/26/22), dry current weight= 127.6#. Registered Nurse (RN) reported resident presenting varied meal intake but tolerating diet well. Recommend continue current dietary interventions as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 9 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0698 ordered. Follow prn Level of Harm - Minimal harm or potential for actual harm Review of the Dietary progress note dated 10/27/2022 included: HD follow-up: Per Dialysis Center Communication (10/26/22), dry current weight= 129.3#. Recommend continue current dietary interventions as ordered. Follow prn Residents Affected - Few Review of the Dietary progress note dated 10/13/2022 included: HD follow-up: Per Dialysis Center Communication (10/12/22), dry current weight= 129.8#. Recommend continue current dietary interventions as ordered. Follow PRN ( as needed). Review of the Dietary progress note dated 9/29/2022 included: HD follow-up: Per Dialysis Center Communication (9/27/22), dry current weight= 129.1 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 9/13/2022 included: HD follow-up: Per Dialysis Center Communication (9/12/22), dry current weight= 129.8 pounds. Spoke with resident and responsible party. Reported good appetite. Daughter/responsible party requests diet to include puree vegetables and meats since it would be easier for resident to eat. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 8/11/2022 included: HD follow-up: Per Dialysis Center Communication (8/10/22), dry current weight= 131.5 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 07/28/2022 included: HD follow-up: Per Dialysis Center Communication (7/27/22), dry current weight= 132.2 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 07/12/2022 included: HD follow-up: Per Dialysis Center Communication (7/11/22), dry current weight= 133.5 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 06/30/2022 included: Note Text: HD follow-up: Per Dialysis Center Communication (6/29/22), dry current weight= 131.5 pounds - weight stable. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 06/14/2022 included: HD follow-up: Per Dialysis Center Communication (6/13/22), dry current weight= 131.7 pounds. - weight stability noted. Recommend continue current dietary interventions as ordered. Will follow PRN. Review of the Dietary progress note dated 05/17/2022 included: HD follow-up: Per Dialysis Center Communication (5/16/22), dry current weight= 131.1 pounds. Recommend continue current dietary interventions as ordered. Review of the Dietary progress note dated 05/3/2022 included HD follow-up: Per Dialysis Center Communication (5/2/22), dry current weight= 129.1 pounds. Recommend continue current dietary interventions as ordered. Review of the Dietary progress note dated 04/12/2022 included: HD follow-up: Per Dialysis Center (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 10 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Communication (4/11/22), dry current weight= 130.9. Recommend continue current dietary interventions as ordered. Review of the Dietary progress note dated 03/29/2022 included: HD follow-up: Per Dialysis Center Communication (3/28/22), dry current weight= 128.4 pounds. Recommend continue current dietary interventions: Review of the Dietary progress note dated 03/17/2022 included: HD follow-up: Per Dialysis Center Communication (3/16/22), dry current weight= 126.7 pounds - resident gained 2 pounds in 1 week. Spoke with HD dietitian and she recommended to discontinue fluid restriction since resident has been stable and there are no concerns. Spoke with resident and daughter/responsible party. New weight and dietary interventions discussed. Recommend continue current dietary interventions: Discontinue fluid restriction In an observation conducted on 12/06/22 at 7:50 AM, Resident #47 was noted in the room with the breakfast tray on her side table. Closer observation showed a meal ticket with the following: 4 ounces of apple juice, fried eggs, 8 ounces coffee, Mighty shake 60 ml and a Renal diet with Fluid restriction of 1200 cc and D:720. The tray consisted of 4 ounces of juice, 8 ounces of milk, and 6 ounces of coffee. Resident #47 was eating on her own in the room with no assistance from staff. Continued observation at 8:10 AM showed that she only ate 20% of her meal with no assistance from staff. In an observation conducted on 12/06/22 at 12:08, Resident #47 was noted in the dining room with the lunch tray. Closer observation showed a meal/tray ticket with the following: Renal, lunch with fluid restriction of 1200 milliliter (ml), dietary (D):720 mls. It showed 120 ml of Apple juice and 120 ml of soup and cream soup or broth only. The tray had 4 ounces of apple juice and 120 ml of soup. During an interview conducted on 12/07/22 at 12:08 PM with the Registered Dietician. When asked about what a renal diet includes as far as restrictions, she stated that a renal diet should be lower in potassium, and we do not add any sodium. She stated that if a resident has a physician's order for fluid restriction, the nurse will verbally inform her of the order and it is her responsibility to break down the total fluid restriction to indicate how much fluids the resident should receive for meals, for nursing and this is further broken down by the shift as well and this is written as an order. Once the order is written for the breakdown of the fluid restriction, she then verbally provides this information to the Certified Dietary Manager (CDM), who in turn ensures that the fluid restriction breakdown is on the meal tickets for the resident. When the RD was asked to explain a meal ticket for Resident #47, she immediately stated that the resident has not been on the fluid restrictions for months. When it was brought to the RD attention that Resident #47 meals/meal tickets are still following the fluid restrictions that were discontinued on 03/17/22, she stated that the fluid restrictions should have been taken off and agreed that Resident #47 has been receiving very few fluids even though the fluid restrictions are not in place at this time. She explained that when nursing receives an order to discontinue fluid restrictions, the nursing staff will inform the RD who turn informs the CDM to remove the fluid restrictions from the meal tickets for the resident. When asked about communication between the facility and the dialysis center, she stated that the facility nursing staff and the dialysis center nursing staff communicate with a Dialysis Communication Form, (these are uploaded into the resident's EMAR) and she does not review any of these documents. She stated that she speaks directly to the dietician at the dialysis center usually every 2 weeks, to discuss weights, labs, diet, and fluid restrictions. She does not always document her discussion that she has with the dietician from the dialysis center, but if she does document the conversation it is documented, under nutrition risk evaluation and a dietary progress note. When the RD was asked care plans (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 11 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few being updated, she responded saying the care plans are updated as needed. When asked if the dialysis center staff (including the dietician) attend the care plan meetings for the resident, she stated they do not attend the care plan meetings. MDS Interview 12/07/22 3:30 PM with Staff C Registered Nurse/Minimum Data Set (MDS) Coordinator, Staff D Registered Nurse/Minimum Data Set (MDS) Coordinator, and Staff E Registered Nurse/Minimum Data Set (MDS) Coordinator when asked how are the dietary care plans updated, they all replied dietary does update their own care plans and the person responsible to do the implementing and updating of dietary care plans would be the responsibility of the Registered Dietician. During an interview conducted on 12/07/22 at 3:55 PM with Staff RD when asked if she had updated the care plan for Resident #47, she said yes. When asked what she updated on the care plan for Resident #47, she said she removed the intervention for fluid restrictions. When asked why it was not removed when the order was received to discontinue the fluid restrictions 03/17/22 she said, I made a mistake. When asked who is responsible for updating the dietary care plans, she stated she is the person responsible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 12 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews the facility failed to ensure proper storage of medications for Resident #26 and 69. The findings included: Review of the facility policy titled Storage of Medications, revision date 08/2020 revealed the following: Medications and biologicals are stored safely, securely, and properly. Also, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. 1) During the initial tour of the facility conducted on 12/05/22 at 9:25 AM, the surveyor found a bottle of prescription shampoo in the bathroom of Resident #26 (photographic evidence obtained). A review of Resident #26's record revealed a Quarterly Minimum Data Set (MDS) was done on 10/27/22. This MDS documented Resident #26 had a Brief Interview of Mental Status (BIMS) score of 13, which indicates she had mild cognitive impairment. This MDS also documented Resident #26 required extensive assistance from staff members for personal hygiene and transfers-this indicates she was unable to shower herself. Review of Resident #26's physician orders revealed an order was written on 10/20/22 for Ketoconazole Shampoo 2% to be used two days per week for a rash on her scalp. Additional observations made on 12/06/22, 12/07/22, and 12/08/22 revealed the prescription shampoo remained in Resident #26's bathroom for the duration of the survey. An interview and observation was conducted on 12/08/22 at 10:10 AM with Staff F, Unit Manager. She stated she checks the resident's rooms weekly to ensure no medications are left in the rooms. The surveyor showed Staff F the shampoo in Resident #26's bathroom. She admitted the shampoo should not have been left in the bathroom and stated she did not know it had been there for the week. She immediately removed the shampoo from the bathroom. 2) During the initial tour of the facility conducted on 12/05/22 at 9:45 AM, the surveyor found a medication cup containing an unidentified white powder in the bathroom of Resident #69 (photographic evidence obtained). A review of Resident #69's record revealed a Quarterly Minimum Data Set (MDS) was done on 09/30/22. This MDS documented Resident #69 had a Brief Interview of Mental Status (BIMS) score of 99, which indicates she had severe cognitive impairment. This MDS also documented Resident #69 was totally dependent on staff members for all activities of daily living. Review of Resident #69's physician orders revealed no active order for any powdered substance-medication or dietary supplement. Additional observations made on 12/06/22, 12/07/22, and 12/08/22 revealed the medication cup containing the unidentified white powder remained in Resident #69's bathroom for the duration of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 13 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 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 0761 survey. Level of Harm - Minimal harm or potential for actual harm An interview and observation was conducted on 12/08/22 at 10:09 AM with Staff F, Unit Manager. She stated she checks the resident's rooms weekly to ensure no medications are left in the rooms. The surveyor showed Staff F the medication cup containing the unidentified white powder in Resident #69's bathroom. She admitted she did not know what the powder was but that it should not have been left in the bathroom and that she did not know it had been there for the week. She immediately removed the medication cup with the powder from the bathroom. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 14 of 15 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 686123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, including holding cold foods at regulatory temperature and using personal items in the food production area. The findings include the following: In a tour of the central kitchen conducted during lunch tray line observation on 12/07/22 at 11:35 AM, the following was noted: 1. The facility's Certified Dietary Manager was observed using the facility's calibrated thermometer. The temperature of a tossed salad was taken and showed to be at 60.4 degrees Fahrenheit, and another tossed salad showed a temperature of 59.3 degrees Fahrenheit. This had the potential to affect the other 13 tossed salads that were noted in the reach-in refrigerator. (photographic evidence obtained) 2. The facility's Certified Dietary Manager was observed using the facility's calibrated thermometer. The temperature of the fruit salad was taken and showed to be 55.7 degrees Fahrenheit, and another fruit salad showed a temperature of 59.5 degrees Fahrenheit. This had the potential to affect the other 37 fruit salads that were noted in the reach-in refrigerator. In this observation, the facility Certified Dietary Manager stated that the tossed salads and the fruit salads are for some residents who like them for lunch today. He further said that he was aware that they were not meeting the required 40.0 degrees Fahrenheit and below and proceeded to put the fruit salads and the tossed salad in the walk-in refrigerator. (photographic evidence obtained) 3. The facility's Clinical Dietitian was observed near the tray line using her cell phone and putting it back in her pocket, and not practicing hand hygiene after using her cell phone. In an interview conducted on 12/07/22 at 3:45 PM, with the facility's Clinical Dietitian, she acknowledged all findings. In an interview conduced on 12/08/22 at 12:30 PM, with the facility's Administrator she was told of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686123 If continuation sheet Page 15 of 15