Health inspection·March 28, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Completion and Accuracy dated 9/2020 states: It is the policy of the facility to adhere to the following procedures related to proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessments of residents will be completed in the format and in accordance with timeframes stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. Procedure 5: The assessment will accurately reflect the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686124 If continuation sheet Page 2 of 6 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 686124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Health Center 9820 N Kendall Drive Miami, FL 33176 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview facility failed to provide the necessary oxygen therapy according to physician's order for one resident (Resident # 453) out of nine residents sampled as evidenced by Resident # 453 receiving oxygen therapy at incorrect rate. Residents Affected - Few The findings included: On 03/25/24 at 7:31 AM Resident #453 was observed in bed with oxygen in progress via nasal cannula at three Liters Per Minute (LPM). (photo evidence) On 03/27/24 at 7:28 AM Resident #453 was observed in bed with oxygen in progress via nasal cannula at a level between 2.5 and three LPM. (photo evidence) Record review of demographic sheet for Resident #453 revealed an admission date of 1/11/2024 and diagnosis that included sleep apnea and shortness of breath. Record review of Resident #453's Minimum Data Set (MDS) dated [DATE] Section C for cognitive status revealed a Brief Mental Status (BIMS) score of 6 on a scale of 0-15 indicating severe cognitive impairment. Section GG for functional status revealed substantial/maximal assistance for transfer, partial/moderate assistance for oral hygiene and supervision touching assistance for eating. Section J for pain revealed no shortness of breath when lying flat. Section O for special treatments revealed oxygen and respiratory therapy. Record review of Care Plan initiated on 03/14/2024 and revised on 03/25/2024 revealed Resident #453 is at risk for ineffective breathing pattern related to Sleep Apnea and Shortness of breath (SOB). Interventions included: Oxygen at two LPM via nasal cannula with humidifier at bedtime for SOB. Administer medication/oxygen as ordered. Adjust head of bed and body positioning to assist ease of breathing. Keep head of bed (HOB) elevated to facilitate easy respirations. Monitor resident's anxiety and give support/assistance as needed. Record review of physician orders dated 3/21/2024 revealed orders for oxygen at two liters per minute via nasal cannula with humidifier every night at bedtime for shortness of breath. On 03/27/24 at 8:43 AM Staff B, Registered Nurse (RN) stated: I have been employed for 14 years at this facility. When I start my shift, I complete a visual assessment of each resident and make sure oxygen is in progress and at the correct level. [ Resident #453] has an order for oxygen two liters per minute via nasal cannula at bedtime. I remove the nasal cannula when [Resident # 453] wakes up. This morning when I rounded [Resident # 453], oxygen was in progress at two liters per minute, and only nursing staff is allowed to touch the concentrator. The Certified Nursing Assistant (CNA) is allowed to remove the nasal cannula as soon as resident awakens but does not touch the concentrator. I test [Resident # 453] oxygen level with a pulse oximeter daily and saturation was 96 % at 7:05 AM on 3/27/2024 which is normal for this resident. When Staff B was asked why the oxygen level was incorrect, Staff B stated: Maybe I didn't properly visualize the oxygen level because I didn't turn on the light in the room to prevent disturbing the resident. On 03/28/24 at 10:05 AM Staff C, RN stated: The protocol for oxygen administration is to take oxygen saturation before or when arrival on shift, follow physician order, have oxygen at bedside, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686124 If continuation sheet Page 3 of 6 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 686124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Health Center 9820 N Kendall Drive Miami, FL 33176 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm make sure nasal cannula is clean. A visual assessment is done before administering oxygen and throughout shift to ensure oxygen level is matching the physician order. Also, we educate family about the amount of liters required, not to touch the concentrator and if they have any question to go to the nurse. CNAs are aware not to readjust the oxygen level and to report to the nurse any concerns. The nurses and CNAs have received in-services about oxygen administration. Residents Affected - Few 03/28/24 10:13 AM Staff D, CNA stated: I have been employed at this facility for 17 years. I am the regular CNA taking care of [Resident #453]. I am aware of any resident on my assignment who require oxygen therapy because the nurses verbalize this me. I do not adjust the oxygen settings and if I see any abnormality I report it to the nurse. I am aware that [Resident #453] uses oxygen during the night. In the morning, I notify the nurse to remove the nasal cannula and if she is busy, I remove the nasal cannula. On 03/28/24 at 11:59 AM, the Director of Nursing (DON) stated: When administering oxygen therapy, the nurse is to follow physician orders; only the nurses are allowed to adjust the level of the oxygen. The CNAs are only allowed to place and remove cannulas. The only responsibility of the CNA is to notify the nurse if they see a problem. Moving forward I will do frequent rounding to monitor the oxygen level of residents who have orders for oxygen and educate the staff about oxygen administration. Record review of the facility's Policy and Procedure for Respiratory Care and Oxygen administration Issued: 3/2020. Revised 10/2022. Standard: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Guidelines: Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's order for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube care, BiPAP, CPAP or medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686124 If continuation sheet Page 4 of 6 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 686124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Health Center 9820 N Kendall Drive Miami, FL 33176 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain an accurate record for one (Resident #95) out of seven residents reviewed for hospitalization. There was a total of 192 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's policy titled, Documentation in Medical Record Policy and Procedure (implemented April 2020, revised October 2023) documented: Policy Statement: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation; Policy Explanation and Compliance Guidelines: 1) Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy and 4) Principles of documentation include, but are not limited to b) Documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care and/or responses to care. Review of the Demographic Face Sheet for Resident #95 documented the resident was initially admitted on [DATE] with diagnosis that include but not limited to end stage renal disease, dependence on renal dialysis, diabetes mellitus, hypertension, and absence of right leg below knee. The resident was discharged to the hospital on 3/18/24 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #95 dated 2/25/24 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required total dependence for ADLs (Activities of Daily Living). The resident received dialysis services. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for January 2024, February 2024 and March 2024 documented the resident was receiving medications for diabetes mellitus, depression, and peripheral vascular disease. Review of the Progress Notes for Resident #95 documented: Dated 3/18/24 08:50-Health Status Note: Patient alert and disorient, change mental status, Vital signs were taken; MD (medical doctor) notified, new order carried out; Dated 3/18/24 09:32-[Resident #95 ] Transfer Form Note: Resident transferred to [ local hospital] for other outside dialysis center and Dated 3/18/24 09:55-Health Status Note: Patient transfer to [local hospital] via [local emergency services] as per MD order with diagnosis: Hypoxemia and change mental status. Review of Resident #95's Transfer Form, dated 3/18/24 documented: Sent to [local hospital] on 3/18/24 for outside dialysis catheter. Interview and record review with the Director of Nursing (DON) on 3/28/24 at 1:24 PM. The (DON) stated: On 3/18/24 at 08:50-Health Status Note: Patient alert and disorient, changed mental status, Vital signs were taken; MD notified, new order carried out. On 3/18/24 09:32- [ Resident #95] Transfer Form Note: Resident transferred to [local hospital] for other outside dialysis center. This is an error of the documentation. It should have read the change in mental status and Hypoxemia. The patient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686124 If continuation sheet Page 5 of 6 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 686124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Health Center 9820 N Kendall Drive Miami, FL 33176 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 was transferred to [local hospital] via [local emergency services] as per MD order with diagnosis of Hypoxemia and change mental status. 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: 686124 If continuation sheet Page 6 of 6