Health inspection·September 19, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to secure residents' confidential information on two ([NAME]-1st floor, Medication Cart 1 and 5th floor, Medication Cart 2) out of four medication carts: as evidenced by unattended Medication Carts noted with unlocked computer screens displaying residents' confidential information during medication administration. There were 288 residents residing in the facility at the time of the survey.The findings included: Observation on 09/16/2025 at 9:47 AM, on the 5th floor, revealed Medication Cart 2 was left unattended and the computer's screen unlocked with visible resident information. (Photographic evidence). The Surveyor notified Staff C, Registered Nurse (RN) of the identified concern. Staff C, RN revealed she did not realize she had left the computer screen open. On 09/16/2025 at 10:15 AM, observation on the 1st floor revealed Medication Cart 1 unattended and the computer screen unlocked with visible resident information. (Photographic evidence). The Surveyor notified Staff D, RN of the identified concern. Staff D, RN revealed he only stepped a few feet away from the computer to assist a resident and came right back. Record review of a Policy titled, Preparation and General Guidelines: May 2022 indicate:Policy: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is maintained always for all resident information (e.g., Medication Administration Record (MAR) [by closing the MAR book/covering the MAR sheet or computer screen when not in use.Interview on 09/16/2025 at 02:10 PM, the Director of Nursing (DON) stated: During medication pass, the staff member provides privacy depending on the situation and always asks the resident if it is acceptable first. To ensure privacy, the staff either pulls the resident away from others or brings them back to their room. In shared rooms, curtains and doors are closed. Medications may be administered in the activity room, but only with the residents' consent. Before leaving the cart, the staff member locks it and ensures all resident information is secure. The computer screen is never left open unattended and locks automatically every 30 seconds.Interview on 09/16/2025 at 9:47 AM, Staff C, RN stated: I did not realize I left the computer screen open. I receive frequent education from the nurse educator about privacy and HIPAA.Interview on 09/16/2025 at 10:15 AM, Staff D, RN stated: I only stepped a few feet away from the computer to assist a resident and came right back. I have only been a nurse here for one month and recently received education on privacy and HIPPA recently for my training virtually and by my preceptor. Residents Affected - Few Page 1 of 5 105030 105030 09/19/2025 Miami Jewish Health Systems, Inc 5200 NE 2nd Avenue Miami, FL 33137

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, interview and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for one (Resident # 55) out of one sampled resident who has a primary diagnosis of Acute Respiratory Failure. As evidenced by the resident's nasal canula (NC) was not in nostrils. The findings included.Observation on 09/16/2025 at 11:07 AM, Resident #55 was in bed with eyes closed, Oxygen (02) running at two (2) Liters per Minute (LPM) via Nasal Canula (NC), NC not in resident's nostrils. The surveyor requested to see the assigned nurse in resident's room.On 09/16/2025 at 11:14 AM Licensed Practical Nurse (Staff F), positioned the 02 tubing in the resident's nostrils, checked the resident's oxygen saturation on the right index finger, the reading was100.On 09/17/2025 at 10:53 AM, Resident #55 was observed in bed, receiving morning care, 02 running at 2 LPM via NC, nasal tubing position correctly in nostrils.During observation on 09/18/2025 at 10:00 AM, Resident #55 noted in room receiving morning care from staff, 02 tubing positioned in nostrils, no distress noted.Review of the medical records for Resident #55 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Atherosclerotic Heart Disease of Native coronary Artery without Angina Pectoris.Review of the Physician's Orders Sheet for September 2025 revealed Resident #55 had orders that included but not limited to: Oxygen 2 LPM via nasal cannula continuous-every shift for shortness of breath.Record review of Resident # 55's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments and Procedures documented the resident is receiving oxygen therapy.Review of Resident #55 Care Plans Reference Date 06/26/25 documented: The resident is on oxygen therapy continuously every shift for shortness of breath, 02 less than 94%. The resident will have no sign and symptoms of poor oxygen absorption through the review date. Interventions include-Change residents position every 2 hours to facilitate lung secretion movement and drainage.Interview on 09/16/2025 at 11:20 AM Licensed Practical Nurse (Staff F) revealed the resident is not alert and oriented and is nonverbal, so education with the resident has not been completed. Staff F stated: I do frequent rounds for this resident because he takes his oxygen tubing off sometimes. Staff F reported she does not know if this a regular behavior for the resident because she does not work with the resident regularly.Interview on 09/16/2025 at 11:38AM, Registered Nurse, Nurse manager (Staff H) stated: This resident pulls his tubing off frequently, the staff have been educated to check on the resident often. The resident is not alert oriented and is non-verbal. As a result, education has not been provided to the resident. All we can do is frequent rounds checking on the resident and alert the nurse if the resident's nasal canula needs to be repositioned correctly.Review of the facility policy and procedures titled, Oxygen Administration revision date November 18, 2024, states: Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. In patients with hypoxemia, the cardiopulmonary system compensated by increasing ventilation and cardiac output. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. Reducing cardiac workload is especially important when disease or injury-such as myocardial infarction (MI), sepsis, or traumas already stressing the heart. Hypoxemia causes pulmonary vasoconstriction and subsequent pulmonary hypertension, which increases the workload of the right side of the heart. Oxygen administration can reverse pulmonary vasoconstriction, decreasing right ventricular workload. Oxygen administration has only limited benefit for treatment of hypoxia Residents Affected - Few 105030 Page 2 of 5 105030 09/19/2025 Miami Jewish Health Systems, Inc 5200 NE 2nd Avenue Miami, FL 33137

F 0695 caused by anemia because of the blood's limited oxygen-carrying capacity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105030 Page 3 of 5 105030 09/19/2025 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 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 observation, records reviewed and interviews, the facility failed to ensure narcotics/ controlled substances were reconciled for one ([NAME] 3, Medication Cart #2) out of ten medication carts observed in the facility. There were 288 residents residing in the facility at the time of this survey.The findings include. On 09/17/2025 at 10:00 AM during the narcotic count and review of [NAME] (3) Medication Cart #2 with Licensed Practical Nurse (Staff I), the narcotic count was inaccurate for Resident # 127's Clonazepam oral tablet 1milligrams (mg). The narcotic count sheet revealed that the last tablet was signed out as given at 10:00 PM on 09/16/25 and the remaining tablets noted as 19. The bingo card/packet count was 18. In addition, the narcotic count was inaccurate for Resident # 255's Lacosamide Oral Tablet 100 milligrams (mg) tablet. The narcotic count sheet revealed that the last tablet was signed out as given at 06:39 PM on 09/16/25 and the remaining tablets noted as 56. The bingo card/packet count was 55. Licensed Practical Nurse (Staff I) acknowledged the discrepancies and revealed she forgot to sign out the medication and was trying to sign out the medications before the surveyors got to her cart. Licensed Practical Nurse (Staff I) proceeded to sign out the medication (Lacosamide 100 mg, 1 tablet on the bingo card as given on 9/17/25 at 9:30AM. Review of the Electronic Medication Administration Record (EMAR) revealed Resident # 127's Clonazepam oral tablet 1milligrams (mg), (1) tablet was given on 09/17/25 at 9:00 AM and Resident #255's Lacosamide Oral Tablet 100 milligrams (mg), (1) tablet was given on 09/17/25 at 9:00 AM. Interview on 09/17/25 at 10:05 AM Licensed Practical Nurse (Staff I) revealed the facility's policy is to sign out narcotic medications immediately after taking medications from the bingo card and document as given after the medication has been taken by the resident; and she just did not get around to signing off the medications.Interview on 09/18/25 at 3:30 PM the Director of Nursing (DON) revealed on 09/16/25 they had started Performance Improvement Plans for identified concerns regarding medication administration procedures, protecting Personal Health Information (PHI), signing out control substances. Review of the facility's policy and procedure titled Disposal of Medications and Medication-Related Supplies dated May 2022 states: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal and state laws and regulations. 105030 Page 4 of 5 105030 09/19/2025 Miami Jewish Health Systems, Inc 5200 NE 2nd Avenue Miami, FL 33137

F 0880 Provide and implement an infection prevention and control program. 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 interviews, the facility failed to follow infection prevention and control procedures for two (Resident #209 and Resident #302) out of 35 residents sampled. As evidenced by Resident #209's Incentive Spirometer and Resident # 302's Bilevel Positive Airway Pressure (BIPAP) machine was observed stored at bedside with no protective covering. The findings include.During observation on 09/16/2025 at 11:47 AM Resident #209 was in bed awake, oxygen (02) running at two (2) Liters per minute (Lpm), Incentive spirometer stored on bedside table with no protective covering (Photographic evidenced).Observation on 09/17/2025 at 11:00 AM and on 09/18/2025 at 01:27 PM the Incentive Spirometer was noted on the bedside table in a resealable plastic bag dated 09/17/25.Review of Resident # 209 medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Chronic Obstructive Pulmonary disease, Chronic Respiratory Failure with Hypoxia.Observation on 09/16/2025 at 11:51 AM Resident # 302 was in bed awake, a BIPAP machine noted on the bedside table with no protective covering (Photographic evidenced).Observation on 09/17/2025 at 10:58 AM and on 09/18/2025 at 2:36 PM the BIPAP machine was observed on the bedside table in a resealable plastic bag dated 09/17/25.Review of the medical records for Resident # 302 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Acute and Chronic Respiratory Failure with HypoxiaInterview on 09/18/25 at 11:18AM Registered Nurse (Staff G) assigned to Resident # 209 and Resident # 302 reported that all respiratory equipment when not being used are stored in a dated [brand] bag, the [brand resealable plastic bags] are changed weekly on Sundays and as needed. We store respiratory equipment in [brand resealable plastic bags] to prevent infection to the residents. During my shift I conduct rounds for my residents every two hours and sometimes more often depending on the resident.Interview on 09/18/25 at 11:26 AM Licensed Practical Nurse (Staff F) assigned to Resident # 209 and Resident # 302's unit revealed, respiratory equipment when not being used is stored in a dated [brand resealable plastic bag], the [brand resealable plastic bags] are changed weekly and as needed. The reason for storing the respiratory equipment in the [brand resealable plastic bag] is to prevent infection. During my shift I check on my residents every one to two hours, high risk residents are checked on every thirty (30) minutes.Interview on 09/18/25 at 11:35AM Registered Nurse Unit Manager (Staff H) was shown photographic evidence. Staff H stated: I will reeducate all the nursing staff on infection control procedures. Respiratory equipment is stored in a dated [brand resealable plastic bag] and changed weekly. The date on the [brand resealable plastic bag] is the date the bag was changed.Review of the facility policy and Procedure titled Infection Prevention and Control Plan dated February 2022 states: The facility maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and healthcare workers. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory and accrediting agencies. Residents Affected - Few 105030 Page 5 of 5