Health inspection·January 30, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Interview on 01/30/25 at 01:13 PM, Staff C, Certified Nursing Assistant (CNA) revealed the razors are kept in the supply room. Resident #24 shaves independently and she does rounds to check on him to make sure he is finished; if she sees razors on the nightstand or in an open dresser she would take it and put it away and the resident will ask for it when he needs it. The resident has never had a shaving incident since she has worked with him. Residents Affected - Few Review of the facility policy and procedure regarding safe and homelike environment 04/2023, states the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of the facility policy and procedure regarding Incidents and Accidents 03/2023, states it is the policy in this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident and to ensure residents receive adequate supervision to prevent accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 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 observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for one Resident (Resident #27) out of 25 sampled residents. As evidenced by, during several observations, Resident #27's oxygen was being administered via nasal cannula at the incorrect rate. There were 98 residents residing at the facility at the time of the survey. Residents Affected - Few The findings included: On 01/27/25 at 07:44 AM Resident # 27 was asleep in bed; Oxygen (02) via Nasal cannula (NC) noted running at 2 liters per minute (LPM). On 01/28/25 at 07:35 AM Resident #27 was in bed asleep, 02 running at 2 LPM via NC. On 01/29/25 at 07:54 AM resident in bed awake, 02 running at 2 LPM via NC, no distress noted. Review of Resident # 27's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Respiratory disorders in diseases classified elsewhere, Respiratory failure, unspecified with hypoxia. Review of the Physician's Orders Sheet for January 2025 revealed Resident #27 had orders that included but not limited to: O2 at 3 liters a minute via nasal cannula continuously every shift for Respiratory Failure. Review of Resident #27 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 10, on a 0-15 scale indicating the resident is moderately impaired cognitively. Section GG for Functional status indicated the resident is dependent for activity of daily living (ADLs). Section O for Special Treatments revealed Resident #27 is receiving oxygen therapy. Review of Resident #27 's Care Plans Reference Date 11/27/24 revealed: resident is at risk for respiratory complications related to: obstructive sleep apnea, respiratory failure. Date Initiated: 03/09/2023 Revision on: 12/01/2024. Resident will be free of signs/symptoms of respiratory distress and maintain optimal functioning within limitations imposed by disease process through review date. Interventions Included-Educate resident and or health care decision maker on respiratory health. Educate resident in energy conservation techniques and pursed lip breathing. Encourage resident to express feelings of fear and anxiety and provide verbal and nonverbal support. Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects. Observe for increased wheezing and or lower activity tolerance and report to Physician (MD) as indicated. Observe respiratory rate, signs and symptoms of dyspnea, use of accessory muscles indicating respiratory distress and report to MD as indicated. Obtain labs as ordered and report to MD as indicated. Provide respiratory treatment as ordered and monitor effectiveness. Interview and observation on 01/29/25 at 09:40 AM; Registered Nurse (Staff A) stated: I check the resident's oxygen orders in the computer system and then during my rounds, I check to make sure the orders match what the resident is receiving. The surveyor and Staff A checked the resident's oxygen concentrator together in the resident's room. The oxygen level on the concentrator was infusing at 2 LPM and acknowledged_ the orders for the resident's oxygen is 3 LPM via NC. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/30/25 at 10:17 AM; the Director of Nursing (DON) revealed the nurses have been in-serviced regarding checking their assigned resident's oxygen orders during their shifts, also at the beginning and the end of their shift. Review of the facility's policy and procedure titled Oxygen Administration revision date 05/04/2022 states: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under the orders of a physician, except in the case of an emergency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the proper rotation of Dietary Medication supplements. As evidenced by, during observation of first floor's Medication Storage Room, two nutritional supplements were found to be expired. There were 98 residents residing in the facility at the time of the survey. The findings included: On [DATE] at 11:13 AM, During Medication Storage Room observation with Registered Nurse (Staff A), two Vanilla Nutritional Drinks were found in the 1st floor medication storage room with an expiration date of [DATE]. Interview on [DATE] at 12:13 PM, Registered Nurse (Staff A) stated: these supplements are used for residents during medication administration as prescribed, particularly residents who do not want their medications with water. The nurses and the nursing supervisors check the medication storage rooms daily and on each shift. Interview on [DATE] at 10:27 AM, the Director of nursing (DON) stated: Nurses are responsible for checking the medication storage room daily on their shifts. In addition, the central supply clerk and the nursing supervisors will be checking the medication storage rooms on Mondays and Fridays. Review of the facility policy titled Medication Storage revision date [DATE] states: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 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 686125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on Observation and interview, the facility failed to implement infection control standards and procedures related to Soiled Utility Rooms. As evidenced by during focused observations the three Soiled Utility rooms in the facility were found to be unlocked. There were 98 residents residing in the facility at the time of the survey. Residents Affected - Some The findings included: On 01/28/25 at 10:09 AM Focus tour with the surveyor and Registered Nurse Infection Control Preventionist -The two soiled utility rooms on the second floor and the soiled utility room on the first floor were observed to be unlocked. Infection preventionist stated the soiled utility rooms are unlocked during the day. Interview on 01/28/25 at 10:24 AM Licensed Practical Nurse Supervisor, first floor (Staff B), stated herself and the nurses on the first floor have the keys to the soiled utility room, the door is supposed to always remain locked and if staff needs to enter the soiled utility room, they have to ask the nurses or her to unlock the soiled utility room. Interview on 01/30/25 at 07:45 AM Director of Nursing (DON) stated keyed entry locks have been installed on the 3 soiled utility room doors by the maintenance director as of 1/29/24. Staff have been educated and given the code for entry to the soiled utility rooms. Review of the facility policy titled Infection Prevention and Control Program revision date 01/15/2025 states: 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 686125 If continuation sheet Page 6 of 6