Inspection·September 14, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for one (Resident #13) out of four residents whose clinical records were triggered and reviewed for written evidence of provision of information regarding formulating an advanced directive. There were 58 residents residing in the facility at the time of the survey. The findings included: Record review of the Resident's Rights Regarding Treatment and Advance Directives Policy and Procedure, revised 4/2023 documented: Policy-It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive. Policy Explanation and Compliance Guidelines: 1) On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive and 2) The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. Review of the Demographic Face Sheet for Resident #13 documented the resident was admitted on [DATE]. Review of Resident #13's electronic clinical record showed the Advance Directive Informed/Consent Form was not completely filled out and not signed and dated. On 9/14/23 at 10:20 AM, interview and record review with the Admissions Director. She stated, They (advance directives) are done on admission, when you go through the admission agreement. I ask them if they have a living will, health care proxy and we are to assist if they want to put it in place. Advance Directive Informed/Consent Form is in the admission packet. The next page is for the resident or the resident's representative to sign it. I see the form in her admission packet and the resident did not acknowledge it nor sign it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 2 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (Resident #13) out of 16 sampled residents was not verbally abused by facility staff. The findings included: Record review of the facility's Abuse, Neglect and Exploitation Policy and Procedure dated 10/1/2022 included, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Verbal Abuse - means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. III. Prevention of Abuse, Neglect and Exploitation - The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of residents property and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect; VII. Reporting/Response - The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, adult protective services and other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Review of the Activities of Daily Living (ADLs) Policy and Procedure, revised 1/2023 documented: Policy-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate. Care and services will be provided for the following activities of daily living: 1) Bathing, dressing, grooming and oral care; 3) Toileting. Policy Explanation and Compliance Guidelines: 3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Observation and interview of Resident #13 on 9/11/23 at 8:02 AM revealed, the resident sitting in a wheelchair in her room. She stated, The nurse [ ], Staff C, Licensed Practical Nurse (LPN) and the CNA (Certified Nursing Assistant) [ ], Staff D, are very disrespectful to me. I had surgery and came back to the facility on August 1 and I had a messy diaper. The CNA [ ], Staff D was very rough with me and I told her so. She told me that she would leave me alone and not change me. I told the nurse [ ], Staff C, LPN and she didn't say anything. I reported it to the DON (Director of Nursing) and they called both of them down. The nurse [ ], Staff C LPN said to me, they are going to be wondering where you are and I am going to make sure that you are gone. Every Monday and Tuesday I have to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 3 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 endure this. They still provide care to me. I am the resident council president. I told the previous DON and I don't know if anything was done. The resident started to cry as she started talking about the encounter. Level of Harm - Actual harm Residents Affected - Few A team meeting with the Administrator and DON on 9/11/23 at 8:48 AM was conducted to discuss the abuse and dignity allegation from Resident #13. The current Administrator and the current DON were not aware of Resident #13's allegations. Review of the Demographic Face Sheet for Resident #13 documented, the resident was admitted on [DATE] with a diagnosis of idiopathic progressive neuropathy, hypertension, anxiety disorder, major depressive disorder, schizoaffective disorder bipolar and insomnia. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #13 documented, the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and she was able to make her needs known and she required limited assistance with one person physical assist for ADLs (activities daily living). Review of the ADL (Activities of Daily Living) care plan for Resident #13 (written 10/09/22) documented, the following: Focus-Resident is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to chronic disease process; Goal: Resident will maintain highest capable level of ADL ability throughout the next review period as evidenced by his/her ability to perform ADLs and Interventions: Assist resident with ADL's as needed, encourage residents participation. Review of the State Immediate Abuse Report concerning the allegation from Resident #13, the report documented the following: On September 11, 2023 at approximately 10:00am, resident reported to AHCA surveyor that on August 3, 2023, while CNA [ ], Staff D was cleaning her up, she stated that she told [ ], Staff D that she was being rough and hurting her. The resident stated, She yelled and said that she was going to leave and left the room. The resident stated that after making that statement [ ], Staff D left her alone. The resident stated that she called for assistance and [ ], Staff D was the one who returned to her room. The resident stated that [ ], Staff D came in and said to her, You're going to fight me and if I lose my job, I don't really care. The resident also stated the at the nurse [ ], Staff C LPN was standing at the door watching and did nothing or said anything. Both staff were suspended, pending full investigation. In-service on Abuse and Neglect initiated and ongoing. Investigation initiated and statement obtained from resident. Statement and ongoing investigation was reviewed with resident. Observation and interview with Resident #13 on 9/13/23 at 10:20 AM revealed, the resident sitting in a wheelchair in her room, watching tv. She stated, Thank you. I am so happy now that the nurse and cna are no longer taking care of me. On 9/14/23 at 7:50 AM, interview with Staff E, Registered Nurse (RN). She stated, She is alert and oriented times three. She requires limited assistance for ADLs. She receives medication every four hours for pain related to hip surgery. The resident is very pleasant and not difficult to work with. I work with her on Wednesdays, Thursdays and Fridays. When she presses the call light, we answer immediately. When she presses the call light, she needs assistance. She doesn't just press it, to press it. On 9/14/23 at 8:54 AM, interview with the DON. She stated, I went to speak to the nurse [ ], Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 4 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few C LPN and the cna [ ], Staff D on the unit. I sent them home pending investigation. I spoke to the resident and she wrote a statement. She was getting care from the cna [ ], Staff D and the cna [ ], Staff D left her. She didn't finish she put on the light and the same cna [ ], Staff D came to finish her. While the cna [ ], Staff D was speaking to her, the nurse [ ], staff C was standing in the hallway. She said the cna [ ], Staff D said to her you want to fight me so you can get me fired, I don't care if I get fired. The nurse [ ], Staff C was in the doorway with an attitude and didn't say anything because she doesn't like me. On 9/14/23 at 8:56, interview with the Administrator. She stated, We filed an abuse and neglect report with [ ] state agency once the allegation of abuse was brought to our attention. The nurse [ ], Staff C and can [ ], Staff D were sent home and the investigation is still ongoing. On 9/14/23 at 12:16 PM, interview with Staff F, CNA. She stated, She helps me when I give her care, she is not total. She puts on her own clothes, goes to the bathroom by herself. I make up her bed. When she came back from the hospital she was total care, but she is better now. When she puts the light on, when I see it, I go to her and give her help. She is very alert. I don't have any problems with her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 5 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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, the facility failed to ensure two residents (#12 & #301) out of 16 sampled residents were free from the use of physical restraints. As evidenced by resident's bed positioned in a concave position ( the head and foot of the bed were elevated) and one bedside chair was positioned on each side of the bed preventing the resident from getting out of the bed without assistance. There were 58 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: 1. During Observation 09/11/23 at 10:48 AM, Resident #12 was in bed, awake, crying out for someone in Spanish. The residents bed was in a concave position with the head and feet elevated. There was one bedside chair on each side of the bed and the chairs were placed close to the bed. On 09/12/23 at 07:53 AM, Resident #12 was observed in bed asleep, and the bed was in a low position. The bed was observed in a concave position, sunken in the middle, the head and feet were elevated, there was one bedside chair positioned next to the bed on both sides of the bed. During observation on 09/13/23 at 08:36 AM, Resident #12 was observed in bed in a sitting position, being fed breakfast by a Certified Nursing Assistant (CNA), and no distress was observed. Review of the medical records for Resident #12 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included, but were not limited to: Parkinson's disease, Unspecified Dementia. Review of the Physician's Orders Sheet for September 2023 revealed, Resident #12 had orders that included but were not limited to: Clonazepam Oral Tablet 0.5 Milligram (MG) (Clonazepam)- give 0.5 mg orally two times a day for Anxiety. Melatonin Oral Tablet 3 MG (Melatonin)-Give 1 tablet orally at bedtime for Insomnia. Record review of Resident #12 's Quarterly Minimum Data Set (MDS) with a reference date 07/23/2023 revealed, Section C for Cognitive patterns was unable to be determined. Section E for Behaviors documented, no potential indicators of psychosis, no behaviors exhibited. Section G for Functional Status documented-The resident is totally dependent for activities of daily living with one person assistance with eating requiring extensive assistance. Section J for Health Conditions documented the resident had no falls. Section P for Restraints documented no bed rails, trunk or limb restraint used in bed, no trunk or limb restraint used in the chair or out of bed, no chairs prevent rising, no bed, chair or wander alarms were used. Record review of Resident #12's Care Plans dated 07/21/2023 revealed: The resident has impaired cognitive function/impaired thought processes related to Dementia. Interventions include-Ask yes/no questions in order to determine the resident's needs. Avoid activities with overly demanding tasks. Cue, reorient and supervise resident as needed. Discuss concerns about confusion, disease process, placement with responsible party as needed. Face when speaking and make eye contact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 6 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Resident has the potential for falls and falls related injury related to Impaired cognition, Impaired mobility, and Incontinence. Interventions included-Minimize risk for falls through next review date. Anticipate needs and provide assistance as needed. Call light within reach and encourage use for assistance as needed. Keep frequently used items within reach. Report falls to the physician and responsible party. Report to the physician any side effects associated with the resident's medication use. Residents Affected - Few 2. During observation on 09/11/23 at 07:53 AM, Resident #301 was in bed, with bilateral floor mats observed, the bed was in the lowest position, and one bedside chair was positioned on each side of the bed. On 09/12/23 at 07:30 AM, Resident #301 was observed in bed, the bed was in the lowest position, there were bilateral floor mats next to the bed. The resident responded to all questions asked with the same answer, and an interview couldn't be completed. On 09/13/23 at 08:32 AM, Resident #301 was observed in bed, being fed breakfast by a Certified Nursing Assistant (CNA), bilateral floor mats were observed, and no distress noted. Review of the medical records for Resident #301 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Unspecified sequelae of cerebral infarction, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, and fall on same level. Review of the Physician's Orders Sheet for September 2023 revealed, Resident #301 had orders that included but were not limited to: Sertraline HCl (Hydrochloride) Tablet 50 Milligram (MG)-Give 1 tablet by mouth one time a day for Depression. Record review of Resident #301 's admission Minimum Data Set (MDS) with a reference date of 08/10/2023 revealed: Section C for Cognitive patterns documented-Brief Interview for Mental Status Score is 14, on a 0-15 scale indicating the resident is cognitively intact. Section E for Behaviors documented no potential indicators of psychosis, no behaviors exhibited. Section G for Functional Status documented-The resident requires extensive assistance for activities of daily living with one person assistance with eating requiring only supervision. Section J for Health Conditions documented the resident had a fall prior to admission. Section P for Restraints documented no bed rails, trunk or limb restraint used in bed, no trunk or limb restraint used in chair or out of bed, no chairs prevent rising, no bed, chair or wander alarms used. Record review of Resident's #301's Care Plan dated 08/07/2023 revealed, Resident is at risk for complications related to the use of psychotropic drugs: antidepressants for treatment of depression. Interventions included-Gradual dose reduction as ordered. Monitor for continued need of medication as related to behavior and mood. Monitor changes in mental status and functional level and report to MD as indicated. Monitor for side effects and consult physician and or pharmacist as needed and Obtain psych evaluation as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 7 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident is at risk for falls and fall related injury History of falls, Impaired mobility and seizures. Is also on psychotropic medication. Interventions included-Anticipate needs, provide prompt assistance, ensure call light is within reach and encourage use for assist with standing/transferring and ambulation, Invite, encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs. Keep frequently used items within reach, Needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach. Observe for side effects of any drugs that can cause: (If noted, report to nurse) Gait disturbance Orthostatic hypotension Weakness Sedation Lightheadedness Dizziness Change in Mental Status. Report to physician if abnormal findings. Referral for screen & treatment as needed. Interview on 09/11/23 at 08:25 AM with Licensed Practical Nurse(LPN, Staff C), from the 2nd floor unit. Staff C was shown the two chairs at Resident #301's bedside- placed at the middle of the bed, positioned close to the bed. Staff C stated, they are not supposed to be there and proceeded to move both chairs. Staff C reported, she had checked on all her residents during rounds. Interview on 09/11/23 at 10:48 AM with Certified Nursing Assistant (CNA - Staff B) from the 7:00AM-7:00PM shift, 2nd floor, when asked about Resident #12's bed and chair positioning, Staff B reported, I am assigned to this resident today, each resident only gets one chair at bedside, I will remove one and the reason the bed is in this position is because the resident is always trying to get out of the bed. Interview on 9/12/23 at 10:55AM with the Director of Nursing (DON) revealed, when told of the findings regarding the bedside chairs positioned on each side of the resident's (#12, #301) bed and the bed positioning, the DON stated, this is a restraint free facility, what the persons involved are doing is trying to make sure the resident does not get out of bed. They are supposed to make frequent rounds to check on the residents. I will be conducting an in-service with all nursing staff about restraints. We do not restrain the residents, this facility is restraint free, and I will be having a conversation with all the staff immediately. Review of the facility's policy and procedure titled, Restraint Free Environment, revision date 1/2023 documents: It is the policy of this facility that each resident shall retain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrants the use of restraints. Physical restraints refer to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot easily remove, which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: Placing a resident on a concave mattress so that the resident cannot independently get out of bed. Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 8 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Record review of the Demographic Face Sheet for Resident #13 documented, the resident was admitted on [DATE] with a diagnoses of idiopathic progressive neuropathy, hypertension, anxiety disorder, major depressive disorder, schizoaffective disorder bipolar and insomnia. The resident was discharged to the hospital on 7/31/2023 for surgery. The resident was readmitted to the facility on [DATE]. Review of the Admit/Readmit Screener Form for Resident #13 documented the following: Dated 7/31/2023-Resident transferred to [ ] local hospital for left hip replacement. Review of the Bed Hold Policy Form for Resident #13 revealed there was no bed hold policy form documented in the resident's electronic chart for the hospital transfer dated 7/31/2023. On 9/11/23 at 8:16 AM, interview with Resident #13 revealed, she stated, I went to the hospital on August 1 for surgery. On 9/14/23 at 9:11 AM, interview with the Social Services Director revelaed, she stated, the Bed hold policy was not given because she didn't sign for it. The resident went to the hospital on 7/31/2023 and came back on 8/01/2023 for an outpatient procedure. On 9/13/23 at 9:13 AM, interview with the Director of Nursing (DON). She stated, The resident was transferred out to the hospital for left hip replacement surgery on 7/31/23. She returned on 8/01/23. Based on record review and interview, the facility failed to provide bed hold policies upon discharge to the hospital for three Residents (Residents #4, #13 & #25) out of 16 sampled residents. The findings included: 1) Review of the medical records for Resident #25 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to. Adult failure to thrive, Anorexia, Gastrostomy status. Resident #25 was discharged to the hospital on [DATE]. The resident was readmitted on [DATE]. Further Review of Resident #25's medical records revealed: Resident #25's Bed hold policy form for Discharge Return Anticipated on 08/11/2023 was not completed. Review of the discharge summary progress note for Resident 25 dated 08/11/2023 timestamped 14:30 documented: Upon rounds, Resident observed with blood coming out of his mouth. Assessment done, Resident profusely with blood and clotting coming from mouth. Unable to find the cause of bleeding with resident keeping mouth shut. Vital signs as follows: Blood Pressure 120/79 Temperature: 98.1 Pulse: 124 Heart Rate: 20. Physician made aware, new order given to send resident to emergency room for further evaluation. Paramedics arrived to facility and transferred resident to the local hospital. Responsible party made aware. Interview on 09/13/23 01:17 PM with the Social Services Director (SSD) revealed, when residents are discharged to the hospital, we are not doing the bed hold policy form because we have the capacity to readmit all of our residents. Every resident that wanted to be readmitted to this facility has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 9 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some been able to return. The resident transfer forms are sent to the ombudsman by e-fax or physical fax every week or two weeks depending on how many discharges we have. We do have a bed hold policy form and I will have to follow up with corporate for specific directions moving forward. Review of the facility's policy and procedure titled, Bed Hold Notice Upon Transfer with a revision date of 3/2023 states: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed hold policy and address information explaining the return of the resident to the next available bed. 2) Review of the medical records for Resident (#4) revealed, it was a closed record with an initial admission date of November 11, 2022, a readmission date of September 9, 2023, and a discharge date of September 6, 2023. Review of resident's medical record revealed, diagnoses including Gastrointestinal (GI) hemorrhage and hemorrhage of anus and rectum. Review of the resident's medical record revealed, there is no signed document of the facility's Bed Hold Policy. Review of nurse's note written on September 6, 2023, at 5:47 AM revealed, Certified Nursing Assistant notified nurse that she saw blood in resident's stool, nurse assessed resident, a call was placed to Medical Doctor(MD), waiting for return call and oncoming shift will be updated on resident's condition. Review of Nurse note written on September 6, 2023, at 3:25 PM revealed, a large amount of loose stool with blood, MD notified, and new orders to send resident to local Hospital via ambulance. Interview on 09/13/2023 at 1:15pm with the Social Services Director(SSD) revealed, the facility does have a Bed Hold Policy in place and does not have a form for the Bed Hold policy. The SSD stated, each resident is accepted back due to the facility's current capacity to receive residents. The SSD reported, she will follow up with producing a form for the Bed hold policy. The SSD stated, she sends a Transfer form to the ombudsman via fax, either monthly or weekly and the forms with a confirmation receipts are kept in the office. The SSD, provided a copy of a completed fax sent to the Ombudman regarding the transfer of Resident # 4 to the hospital. The form was dated 09/13/23, and sent at 11:43am. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 10 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. 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, the facility failed to ensure the Quarterly Minimum Data Set (MDS) assessment was accurate related to Ostomy (including urostomy, ileostomy, and colostomy), for one (Resident #12) out of 16 residents sampled. Residents Affected - Few The findings included: Record review of Resident #12's Quarterly Minimum Data Set (MDS) with a Reference Date of 07/23/2023, Section H for Bowel and Bladder documented, the resident has an Ostomy (including urostomy, ileostomy, and colostomy), and is always incontinent of bowel and bladder. During Observation on 9/12/23 at 10:00AM, it was observed Resident #12 did not have an Ostomy (including a urostomy, ileostomy, and colostomy), skin observation did not reveal any signs of having an ostomy. Further review of the medical records for Resident #12 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Parkinson's disease, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and anxiety disorder, unspecified. Interview on 9/13/23 at 1:30PM with Corporate Minimum Data Set (MDS) Specialist/Licensed Practical Nurse (LPN) revealed, when asked about the ostomy coding on the resident's MDS, it was reported it may have been an error in the coding, I'm from corporate and several MDS personnel are editing MDS in the system. the Corporate MDS Specialist reported, you are correct, it is an error, the correction will be done immediately and Regional Nurse Consultant will be signing off on the corrected MDS. Review of the facility's policy and procedure titled, Conducting an Accurate Resident Assessment revision date 1/2023 states: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 11 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 observation, record review and interview, the facility failed to ensure an enteral feeding was administered as prescribed and dated correctly for one (Resident #46) out of 16 sampled residents. The findings included: During observation on 09/11/23 at 08:06 AM, resident #46 was in bed asleep. Glucerna 1.2 tube feeding (TF) was infusing at 70 milliliters per hour (ml/hr.), with a water flush at 50ml/hr. The Glucerna 1.2 formula was dated 9/8/23, the water flush was dated 9/8/23, and the tube feeding syringe was dated 9/11/23. On 09/12/23 at 07:58 AM, resident #46 was observed in bed. The bed was in the lowest position, the head of the bed was elevated, and the tube feeding was infusing at 85 ml/hr., the water flush was infusing at 50 ml/hr. The Glucerna 1.2, water flush and the syringe were dated 9/12/23. On 09/13/23 at 09:35 AM, resident #46 was observed in bed and the head of bed was elevated. The tube feeding was infusing at 85ml/hr., the water flush was infusing at 50ml/hr. The Glucerna 1.2, water flush and the syringe were dated 9/13/23. The hang time of Glucerna 1.2 was 5:30AM on 9/13/23. Review of the medical records for Resident #46 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Metabolic Encephalopathy and Dysphagia, unspecified. Review of the Physician's Orders Sheet for September 2023 revealed, Resident #46 had orders that included but were not limited to: 9/8/23-Enteral Feed every shift Glucerna 1.2 85ml/hr x 20hr via Percutaneous Gastrostomy Tube (PEG). Total volume 1700ml. On 2PM Off 10AM. On 7/12/23-Enteral Feed every shift auto flush 50ml/hr x 20hr via PEG. On 2PM Off 10AM. On 7/18/23-9/8/23-Enteral Feed every shift Glucerna 1.2 80ml/hr x 20hr via PEG. Total volume 1600ml. On 2PM Off 10AM. On 7/14/23-7/17/23-Enteral Feed every shift Glucerna 1.2 70ml/hr x 20hr via PEG. Total volume 1400ml. On 2PM Off 10AM. Record review of Resident # 46's admission Minimum Data Set (MDS) with reference date of 07/15/2023 revealed, Section C for Cognitive Patterns unable to be determined. Section G for Functional Status documented, the resident requires extensive assistance with two persons for activity of daily living. Section J for Health Conditions documented shortness of breath or trouble breathing with exertion, no falls. Section K for Nutritional Status documented no unknown weight loss/gain, Feeding tube-51% of total calories and 501cc(cubic centimeters) of water a day or more. Record review of Resident #46 's Care Plans Date 07/12/2023 revealed: Resident requires an enteral feeding tube to meet nutrition and hydration needs related to: Cancer. Interventions include-Aspiration precautions. Check patency and placement of tube daily and before administrating feedings and/or meds. Check TF residual as ordered. Dietary evaluation and monitoring. Feeding at room temperature (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 12 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm as ordered. Free water as ordered. Head of bed at 30-45 degrees at all times during feeding and flushing. Keep nothing by mouth as ordered. Provide tube feeding as ordered. Weigh resident per facility protocol and alert dietitian and Medical Doctor (MD) to any significant loss or gain. The residents weights in the medical record included: Residents Affected - Few 9/7/2023, 15:17 138.8 Lbs 9/2/2023, 17:45 139.5 Lbs 8/14/2023, 11:32 149.5 Lbs 7/18/2023, 23:35 144.2 Lbs 7/12/2023, 16:45 141.4 Lbs Interview on 9/12/23 at 10:45AM with the Director of Nursing (DON) revealed, the night shift nurse was contacted and stated he changed the resident's formula at 8PM on 9/10/23 (Sunday night). The new tube feeding (TF) orders started on 9/8/23, maybe he had that date in his mind when he was hanging the new TF formula. The nurse that worked on Sunday night, did not work on 9/8/23, I am really not sure what happen with the dates on the resident's formula, but the formula was changed on Sunday nighton 9/10/23. The DON stated, the nurses are responsible for the TF infusions, when a nurse hangs a resident's TF formula, they must put the date and hang time and verify the flow rate for the formula and flushes are correct. Formulas are good for 24 hours after being opened and we also follow the manufacturer's instructions. Interview on 09/12/23 at 01:18 PM with Registered Nurse (Staff A), form the 2nd floor. Staff A reported, the tube feeding formula's (TF) are good for 24 hours, TF's are usually changed on the night shift 7:00PM-7:00AM, Staff A, stated when I do my rounds during my shift I check the feeding rate, date and time on the formula and the water for flushes. If the Certified Nursing Assistants (CNAs) need the TF turned off to provide care, they let the nurses know, and we turn it off for them and remind them to let us know when they are finished with care so we can turn the TF back on. This resident's tube feeing is off at 10AM and starts again at 2PM. Review of the facility's policy and procedure titled, Appropriate use of feeding tubes revision date 1/2023 states: Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary. Policy Explanation and Compliance Guidelines (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 13 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #6-A resident who is fed by enteral means receive the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers. Review of the facility's policy and procedure titled, Assisted Nutrition and Hydration revision date 1/2023 states: Policy Explanation and Compliance Guidelines: 1. The facility will provide nutritional and hydration care and services to each resident, consistent with the residents' comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 14 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure 1) Hand hygiene was conducted between residents during dining and 2) The food service staff were wearing hair restraints properly. The certified nursing aide (CNA) was observed passing breakfast trays to residents without practicing hand hygiene and a Food Service Worker was serving on the lunch tray line without the hair net covering the entire head. This has the potential to affect fifty three residents out of fifty eight residents who eat orally residing in the facility. The findings included: 1) Record review of the Infection Prevention and Control Program Policy and Procedure, revised 8/15/2022 documented: Policy-This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 4) Standard Precautions: b) Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Review of the Hand Hygiene Policy and Procedure, revised 1/17/2022 documented: Policy-Staff shall perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Policy Explanation and Compliance Guidelines: 1) Associates must perform hand hygiene using proper technique consistent with accepted standards of practice; 2) Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands. Observation of the second floor breakfast food trays on 9/11/23 at 8:22 AM. Two food carts arrived on the second floor with breakfast trays. At 8:31 AM, nursing staff went to the food carts to serve breakfast food trays to the residents in their rooms. At 8:33 AM, observed Staff G, CNA (Certified Nursing Assistant) go into the nourishment room, come out and go to the food cart without sanitizing her hands. Staff G, was observed to deliver the trays to the residents and came back to the food cart and got another food tray without sanitizing her hands. Multiple observations were made with Staff G, not sanitizing her hands in between serving the residents. A second observation of the second floor breakfast food trays on 9/12/23 at 7:45 AM revealed, Staff G, CNA, was observed going into the food cart without sanitizing her hands. She proceeded to take the food tray into a resident's room and left out of the room to retrieve a bedside table for the resident and did not sanitize her hands before going back into the resident's room with the bedside table. On 9/12/23 at 8:34 AM, interview with Staff G, revealed, she stated, You are supposed to sanitize your hands before getting the food tray. Open the cart, take the tray and look in the tray to make sure you have everything. If you need something you find it. Then knock on the patients door and ask may I come in and set up the tray. If the patient is a feeder, you put the tray there and come back later to feed the patient. You have to wash your hands with sanitizer and set up the food. I know on yesterday I didn't sanitize my hands. I forgot too. 2) Record review of the Staff Attire Policy and Procedure, revised 10/2019 documented: Policy Statement-It is the centers policy that all Dining Services employees wear approved attire for the performance of their duties. Action Steps-1) The Dining Services Director insures that all staff members (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 15 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 have their hair off the shoulder, confined in a hair net or cap and facial hair properly restrained. Level of Harm - Minimal harm or potential for actual harm Observation of the food service worker, Staff H on 9/12/23 at 11:13 AM revealed, Staff H was wearing a hair net that did not completely cover his hair while working on the lunch tray line. He was also, wearing a beard net. The dietary worker had the front part of his hair out of the hair net and the rest of his hair was covered. Residents Affected - Some On 9/12/23 at 11:14 AM, interview with Staff H, Food Service Worker. He revealed he knew the hair net was supposed to cover his head completely. On 9/12/23 at 11:15 AM, interview with the Food Service Director. She stated, Hair nets are supposed to completely cover the hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 16 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewed, informed the residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. Residents Affected - Some The findings included: Record review for the Arbitration agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The Admissions Director is responsible for the binding arbitration agreements. Review of the facility's Optional Dispute Resolution Agreements/Binding Arbitration Agreement form documented the following: Resident #34 signed and dated the agreement on 12/29/2022, Resident # 6 signed and dated the agreement on 1/16/2022 and Resident #46 signed and dated the agreement on 7/10/2023 and the form failed to show the arbitration agreements provided to the residents included 1) Neither the resident or his/her representative is required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and 2) The binding arbitration agreement allows the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 9/14/23 at 10:41 AM, interview and record review with the Admissions Director and the Administrator confirmed that the Dispute Resolution agreement/Binding Arbitration Agreement forms did not document the following: 1) Neither the resident or his/her representative is required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and 2) The binding arbitration agreement allows the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. Review of the Binding Arbitration Agreements Policy and Procedure, revised 3/2023 documented: Policy-This facility asks all residents to enter into an agreement for binding arbitration. Policy Explanation and Compliance Guidelines: 2) The agreement must: d) Explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility and 3) The agreement must not contain any language that prohibits or discourages the resident or anyone else from communication with federal, state or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees and representatives of the Office of the State Long-Term Care Ombudsman. This policy and procedure was received from the Administrator on 9/14/23 at 11:34 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 17 of 18 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lilac at Silver Palms 14601 NE 16th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewe. The binding arbitration agreements did not provide for the selection of a neutral arbitrator agreed upon by both parties. Residents Affected - Some The findings included: Record review for the Arbitration Agreements on the facility's letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The Admissions Director is responsible for the binding arbitration agreements. Review of the facility Optional Dispute Resolution Agreements/Binding Arbitration Agreements documented the following: Resident #34 signed and dated the Arbitration Agreement on 12/29/2022, Resident #6 signed and dated the Arbitration Agreement on 1/16/2022 and Resident #46 signed and dated the Arbitration Agreement on 7/10/2023 and the Arbitration Agreements failed to show the arbitration agreements provided for the selection of a neutral arbitrator agreed upon by both parties. On 9/14/23 at 10:41 AM, interview and record review with the Admissions Director and the Administrator confirmed that the Dispute Resolution agreement/Binding Arbitration Agreement forms did not document the following: The binding arbitration agreement provide for the selection of a neutral arbitrator agreed upon by both parties. Review of the Binding Arbitration Agreements Policy and Procedure, revised 3/2023 documented: Policy-This facility asks all residents to enter into an agreement for binding arbitration. Policy Explanation and Compliance Guidelines: 2) The agreement must: a) Provide for the selection of a neutral arbitrator agreed upon by both parties. This policy and procedure was received from the Administrator on 9/14/23 at 11:34 AM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 18 of 18