Health inspection·February 25, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews facility failed to administer medications as ordered by a physician in accordance with professional standards for two residents (Resident #1 and Resident #6) out of four sampled residents as evidenced by staff failed to administer an accurate dose of a laxative for Resident #1 and failed to administer a blood pressure lowering medication as ordered for Resident #1. The findings included: Observation on 2/25/25 at 9:12 AM of Resident # 6's medication administration being completed by Staff B, Registered Nurse (RN) revealed the medications administered by mouth included Lactulose 15 ml (milliliters). The label on the bottle of Lactulose read 30 ml daily by mouth (photographic evidence). Review of Resident #6's physician orders revealed order dated 2/21/25: Lactulose Oral Solution 10 gm/15 ml (grams/milliliters) directions: Give 15 ml by mouth in the morning for constipation. Record review of Resident #6's demographic sheet revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that include constipation. Review of Resident #6's Brief Interview for Mental Status (BIMS) revealed a score of 10 out of 15 to indicate moderate cognitive impairment. During an interview on 2/25/25 at 1:45 PM, Staff B, RN was asked about the discrepancies in the label on the Lactulose bottle and the current order noted on the Electronic Medication Administration Record (MAR). At that time Staff B, RN referred to the physical chart and presented a physician orders worksheet dated 2/21/25; the document presented revealed physician ordered to lower Lactulose to 10cc daily. Interview on 2/25/25 at 2:45 PM with the Director of Nursing (DON) about The Lactulose order for Resident # 6; the DON stated: The Lactulose order was clarified with the physician and the order should have been 10 ml daily. An incident report was completed. [Resident #6] was not harmed. Review of a demographic sheet for Resident#1 revealed an admission date of 1/29/25, readmission date of 2/6/25, discharge date s of 2/4/25 and 2/14/25 with diagnosis that included: Hypertensive Heart Disease and Chronic Kidney Disease. Record review of a Medicare 5 day/ Modification of Discharge Return Anticipated MDS (Minimum Data Page 1 of 3 105030 105030 02/25/2025 Miami Jewish Health Systems, Inc 5200 NE 2nd Avenue Miami, FL 33137

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set) reference dated 2/4/25 revealed Resident #1's Brief Interview for Mental Status (BIMS) score was undetermined, and the resident required substantial/maximal assistance for eating and was dependent on staff for transferring. Record review of Resident #1's physician's orders sheet revealed orders dated 1/30/25 for Midodrine Hydrochloric Acid Oral Tablet 5 mg (Midodrine HCl) directions: Give one tablet via Percutaneous Endoscopic Gastrostomy (PEG) Tube every eight (8) hours for Hypotension (Low Blood Pressure) and Vital Signs every 8 hours, 2/7/25 Midodrine HCl Oral Tablet 5 mg (Midodrine HCl) directions: Give 1 tablet via PEG-Tube every 8 hours for hypotension (stopped on 2/10/25) and 2/10/25 Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) directions: Give 1 tablet via PEG-Tube every 8 hours as needed for hypotension for systolic (the top number of a blood pressure reading) less than 100. Review of Nursing Notes revealed on 2/9/25 at 2:24 PM [Resident #1] was noted with High Blood Pressure (B/P) during my shift, resident does not have any hypertension medication, patient had Midodrine scheduled which was not administered. I explained to the son who was in the room that I will contact the Doctor to get an order for hypertension medication, Son verbalizes been scared to Mom's B/P went low with BP medication. I contacted Dr and explained concerns and allergies and also suggested as needed (PRN) medication. Doctor ordered Lisinopril 2.5 mg daily. Son explained about order, medication, dose and time and he verbalized to be agreed. Record review of The Electronic Medication Administration Record and Treatment Administration Records for January and February 2025 revealed Midodrine 5 mg was administered on 1/31/25 at 6:00 AM the recorded B/P was 138/ 71, on 1/31/25 at 2:00 PM the recorded B/P was 167/72, on 1/31/25 at 10:00 PM the recorded B/P was 131/ 60, on 2/1/25 at 2:00 PM the recorded B/P was 143/ 63, on 2/2/25 at 2:00 PM the recorded B/P was 138/65, on 2/7/25 at 2:00 PM the recorded B/P was 136/79, on 2/7/25 at 10:00 PM the recorded B/P was 158/84 and on 2/8/25 at 2:00 PM the recorded B/P was 136/72. Interview on 2/25/25 at 2:20 PM, the Director of Nursing (DON) was asked when nursing staff are required to hold Midodrine if there are no parameters in the order. The DON stated: We practice not to have parameter as standard orders for medications affecting the blood pressure. If a parameter is set that is per physician's order. Our standard is to check residents blood pressure every 8 hours. We also have a reference booklet available to nursing staff if they have any questions about medications. It is located on their laptop. When there is no parameter, the physician did not order it. We have a system where medications are triple checked during the reconciliation process when residents are admitted . On 2/25/25 at 3:45 PM the Staff Pharmacist was asked about the proper administration including parameters of Midodrine; the Pharmacist stated: There is no guidance that says when Midodrine can or cannot be administered. The only contraindication is persistent and excessive supine hypertension. Routine orders for Midodrine don't usually have parameters. Record review of a policy provided titled, Preparation and General Guidelines, May 2022 revealed IIA2: Medication Administration -General Guidelines. Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. 105030 Page 2 of 3 105030 02/25/2025 Miami Jewish Health Systems, Inc 5200 NE 2nd Avenue Miami, FL 33137

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 review the facility failed to ensure drugs and biologicals stored and labeled in accordance with professional principles, as evidenced by one out of three medication carts sampled was left unlocked and unattended with a medical ointment on top of the cart; and discrepancy with labeled orders and Electronic Medication Administration (EMAR). The findings included: On 2/25/25 at 8:43 AM during observation of medication administration conducted by Staff A, Licensed Practical Nurse (LPN) on the 2nd floor, Staff A, LPN stepped away from the medication cart to use the telephone at the nursing station, leaving the medication cart unlocked and a medical ointment on top of the cart. When Staff A, LPN returned to the cart the surveyor asked Staff A,LPN about the protocol for securing medication and storing ointments; Staff A,LPN replied: The cart should be locked when I walk away. The reason I left the cart unlocked when I walked away was because I could still see the cart. It is not okay to leave the cart unlocked. Ointments are kept in the treatment cart. I found this ointment and forgot to place it in the treatment cart. 2)On 2/25/25 at 9:12 AM a medication administration observation was conducted on the 2nd floor with Staff B, Registered Nurse (RN). Staff B, RN administered 15 ml (milliliters) of Lactulose solution as documented in the Electronic Medication Administration Record. However, the Lactulose bottle was labeled to administer 30 ml daily. Record review of a Policy titled, Medication Storage in the Facility dated April 2018 ID1: Storage of Medications revealed Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 105030 Page 3 of 3