Health inspection·January 20, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Discharge Minimum Data Set (MDS) assessment was submitted in a timely manner for one (Resident #95) out of one resident who was triggered for late MDS submissions. The MDS record was over 120 days old. There were 111 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Record review of the facility's Assessment Frequency and Timeliness of the Minimum Data Service (MDS) Assessment Policy and Procedure (implemented [DATE], revised [DATE]) documented: Policy Statement: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI (Resident Assessment Instrument) Manual; Policy Explanation and Compliance Guidelines: 1) The MDS/RAI Coordinator will be responsible for tracking due dates for all MDS assessments; 6) A discharge assessment will be completed within 14 days of the discharge date . Closed record review of the Resident Assessment screen for Resident #95 documented there was a MDS record over 120 days old. Review of the Demographic Face Sheet for Resident #95 documented the resident was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, heart failure, atherosclerosis, hypertension and atrial fibrillation. The resident was discharged on [DATE]. Review of the Discharge Summary Progress Note dated [DATE] timestamped at 17:08 for Resident #95 documented: The resident was observed with loud mourning, unable to speak, weakness to right arm. Vitals rechecked. Call placed right away to emergency services due to resident's status change. Emergency services arrived at the unit and the resident was transferred to a local hospital. Review of the Discharge Return Anticipated MDS, dated [DATE] for Resident #95 documented: The discharge-return was anticipated; It was an unplanned discharge; Discharge to acute hospital; discharge date was [DATE]; The MDS was submitted on [DATE] and was accepted. Review of Social Service Note Progress Note dated [DATE] at 08:36 for Resident #95 documented: The resident's sister telephoned the facility and indicated that the resident expired on [DATE] at the hospital. Review of the Discharge Return Not Anticipated MDS, dated [DATE] for Resident #95 documented: The discharge-return was not anticipated; It was an unplanned discharge; Discharge to acute hospital; Page 1 of 18 105120 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0638 discharge date was [DATE]; The MDS was submitted on [DATE] and accepted. Level of Harm - Minimal harm or potential for actual harm Interview and record review with Staff C, Licensed Practical Nurse (LPN) MDS Coordinator on [DATE] at 11:22 AM. She stated, When we discharge, we code return anticipated when discharged to the hospital. Then after a couple of days if they don't return, I then recode. We have to wait at least 30 days before submitting a new MDS. The Discharge Return Not Anticipated MDS, dated [DATE] documents, Discharge-return not anticipated; Unplanned discharged . He was discharged to acute hospital and the discharge date was [DATE]. I submitted the new discharge MDS on [DATE] and it was accepted. The MDS was late. Residents Affected - Few 105120 Page 2 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

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 record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident #110) out of one resident reviewed for resident assessments. Resident #110 was coded as being discharged to the hospital, but the resident was discharged home. There were 111 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Closed record review of the Demographic Face Sheet for Resident #110 documented the resident was admitted on [DATE] with diagnoses that included paraplegia, hypertension, hyperlipidemia, insomnia and diabetes mellitus. The resident was discharged on 10/21/22. Review of the Discharge Return Not Anticipated MDS, dated [DATE] for Resident #110 documented: The discharge-return was not anticipated; It was a planned discharge; Discharge to acute hospital; discharge date was 10/21/22. The MDS was incorrect. The resident was discharged home and not to the hospital. Review of the Physician's Order Sheet dated October 2022 for Resident #110 documented: DC (discharge) home on [DATE] with medications (Revision dated 10/20/22). Review of the Discharge Care Plan for Resident #110 (written 6/24/22) documented the resident required short term care at the facility and would be discharged home. Review of the Social Service Progress Note dated 10/21/22 at 14:55 for Resident #110 documented: The resident was discharged with the remaining medications. Review of the Health Status Progress Note dated 10/21/22 at 15:19 for Resident #110 documented: Resident left facility via stretcher in stable condition. Resident discharged home with medications and belongings. Interview and record review with the Social Services Director on 1/20/23 at 9:52 AM. She stated, He was discharged home to a new apartment that a family member refurbished for him. He was not discharged to a hospital. Interview and record review with Staff D, Registered Nurse (RN), Unit Manager on 1/20/23 at 10:14 AM. She stated, He was discharged home not to the hospital. Interview and record review with Staff C, Licensed Practical Nurse (LPN) MDS Coordinator on 1/20/23 at 11:04 AM. She stated, Nurses' progress note documents he was discharged home on [DATE]. The Discharge Return Not Anticipated MDS, dated [DATE] documents Discharge-return not anticipated. It was a planned discharged and he was discharged to an acute hospital. His discharge date was 10/21/22. The MDS is incorrect because he went home. Interview and record review with the Director of Nursing (DON) on 1/20/23 at 12:36 PM. He stated, He was discharged home on [DATE] and the MDS documents that he was discharged to the hospital. The MDS is incorrect. 105120 Page 3 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interview the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR). Level I for Serious Mental Illness (SMI) or Intellectual Disability (ID) was accurately completed at the time of admission for one resident (Resident #32) out of one resident whose PASRR was reviewed. This deficient practice has the potential to affect 111 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Observation of Resident # 32 on 01/18/2023 at 09:23 AM. Resident was observed having breakfast seated on his bed. with several juice cans on the side table. Resident #32 reported that he did not drink juices that are not good for his health. On 01/19/2023 at 11:05 AM, Resident #32 was not in his room and was out on pass with his wife. Observation of Resident # 32 on 01/20/2023 at 12:07 PM, revealed the resident in bed with eyes closed and no distress noted. Review of Resident #32's admission record revealed the resident was admitted to the facility on [DATE]. clinical diagnoses included, but not limited to, Parkinson's Disease; Major Depressive Disorder, Single Episode, Unspecified; and Post Traumatic Stress Disorder Unspecified. Review of Resident #32's Level I Pre-admission Screening and Resident Review (PASRR). dated 08/12/2022 Section I Screen Decision Making item A- MI (Mental illness) or suspected MI (check all that apply) was not marked (blank) to indicate if the resident had diagnosis of mental illness. Item B. ID (Intellectual Disability) or suspected ID (check all that apply was also unchecked (blank). Section III revealed the resident was not a provisional admission. Section IV PASRR Screen Completion check marked that the resident had no diagnosis or suspicion Mental Illness (MI) or suspicion of Serious Mental Illness (SMI) or Intellectual Disability. Record review of admission Minimum Data Set (MDS) Section A dated 08/19/2022 revealed the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of admission Minimum Data Set (MDS) dated [DATE] revealed the Resident Brief Interview for Mental Status (BIMS) Summary Score was 12 out of 15 meaning the resident has moderately impaired cognition. Record review of admission MDS Section I for Active Diagnoses dated 08/19/2022 revealed the resident's diagnoses included Parkinson Disease, Depression and Post Traumatic Stress Disorder (PTSD). Review of the Quarterly MDS dated [DATE] indicated in Section N for medications that Resident #32 was receiving antidepressant medications seven (7) days a week. Record review of Care Plan initiated on 08/15/2022 and revised on 11/07/2022. The resident uses antidepressant medication related Depression. Goal: The resident will be minimized from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: · 105120 Page 4 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness each shift. Educate the resident/family/caregivers about risks, benefits, and the side effects of anti-depressant medication use. Monitor/document/report adverse reactions to antidepressant therapy. Record review of physician orders dated 08/23/2022 revealed orders for Venlafaxine HCL Capsule Extended Release 24 Hour 75 milligrams, 1 capsule by mouth one time a day for Depression. Review of Medication Administration Record for January 2023 revealed the resident was receiving Venlafaxine HCL Capsule Extended Release 24 Hours 75 milligrams as ordered. Record review revealed the resident was seen by a psychiatrist on 08/16/2022. Treatment plan: Will follow up in 4-6 weeks or sooner if needed. Resident appears at baseline on current medication regiment listed above, there are no changes or recommendations at this time. Gradual Dose Reduction (GDR) is not recommended at this time, resident in the lowest effective dose. Record review revealed Resident #32 is under psychotherapy, once a week since September 7, 2022. Interview with Staff B, a Licensed Practical Nurse (LPN) on 01/20/2023 at 12:05 PM, revealed the resident is alert and oriented to person, place, and time. His family is very involved and visit almost every day. Yesterday he was out with his wife and came late last night. Staff B reported the resident did not seem depressed, but he received antidepressant medication. She stated the resident likes to go to activities and paint. He is scheduled for physical therapy, but he was so busy with family that he did not follow the schedule very well. Interview with Social Services Director 01/20/2023 at 12:23 PM. She stated the facility protocol is when a resident will be admitted , she discussed with the Interdisciplinary Team (IDT) and decide if the resident can be accepted, they checked the Level I PASRR. She stated for this resident she realized the Level I PASRR was not checked, and it was not completed. She stated she failed in that one. On 01/20/2023 at 1:05 PM, the Social Services Director reported that the Level I PASRR for Resident # 32 was submitted to the State agency. Review of the facility's Policy and Procedures for Resident Assessment-Coordination with PASRR Program implemented on 11/28/2017 and revised 11/28/2022 revealed Policy: This facility coordinates assessment with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the mot integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1-All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a) PASRR Level I- initial pre-screening that is completed prior to admission. 105120 Page 5 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to implement a written care plan to ensure one (Resident #73) out of one resident reviewed for bowel and bladder incontinence received adequate incontinence care and ensure incontinent products were readily available for incontinence care. As evidence by Resident # 73 was left soiled for 3 hours by facility staff. 2) the facility failed to ensure care plan was implemented for the accurate provision of oxygen for two residents (Resident #514 and Resident #70) out of three residents reviewed for oxygen treatment. This has the potential to affect 14 residents receiving respiratory treatment. There were 111 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's Comprehensive Care Plans Policy and Procedure (implemented 11/28/2017, reviewed 7/07/2022) documented the following: Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1) The care planning process will include an assessment of the resident's strengths and needs; 3) The comprehensive care plan will describe, at a minimum the following: a) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Review of the facility's Baseline Care Plan Policy and Procedure (implemented 11/28/2017, reviewed 9/20/2022) documented the following: Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1) The baseline care plan will: a) Be developed within 48 hours of a resident's admission; b) include the minimum healthcare information necessary to properly care for a resident. 1) Observation and interview with Resident #73 on 1/17/23 at 10:14 AM revealed the resident sitting up in bed, watching television (TV) and wearing glasses; No odors noted. She stated, I have been sitting in poop since 7:00 AM. I pressed the call light, they came in here, removed the [adult brief] from my room for another room and never changed me. I want to be changed because I don't want my [private part] burning. The resident reported that she had been sitting in her feces for more than three hours. Observation on 1/17/23 at 10:19 AM revealed a staff member coming into the resident's room while Resident # 73 was being interviewed. The staff member was observed placing a package of adult briefs in the resident's closet. Observation revealed Staff F, a Certified Nursing Assistant (CNA) on 1/17/23 at 10:21 AM entering Resident #73's room. During an interview Staff F, stated, I came in here early this morning because of the light on. I told her I would be back. I was waiting on them to bring [ adult briefs] in. They just brought the [adult briefs] in. I can change her now. Staff F further revealed that the resident pressed the call light at 7:00 AM, asking to be changed but she did not change the resident because breakfast was being served and she did not have any adult briefs in the resident's room. 105120 Page 6 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Demographic Face Sheet for Resident #73 documented the resident was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, hypertension, anxiety disorder, insomnia, and morbid obesity. Review of the Minimum Data Set (MDS) 5-Day Assessment for Resident #73 dated 12/08/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 09 out of 15 indicating mild cognitive impairment and the resident was able to make her needs known. The resident required total dependence with one-person to physical assist for toileting and extensive assistance with one-person physical assistance for ADLs (Activities of Daily Living). Review of Resident's #73's ADL care plan dated 12/01/22 documented: Focus: Resident has ADL self-care deficit, Toilet use: Total; Goal: Resident will maintain a sense of dignity by being clean, dry, odor free and well-groomed and risk for further decline. Will be minimized through next review date; Interventions: Assist with ADLs as needed. Review of Resident's #73's Bladder and Bowel care plan dated 12/01/22 documented: Focus: Resident is always incontinent of B&B (Bladder and Bowel) functions r/t (related to) functional decline and is at risk for alteration in skin integrity and infection. Sometimes, the resident states that she is soiled, and she is actually dry (written 12/01/22; revised 1/17/23 to include [Sometimes, the resident states that she is soiled and she is actually dry by Social Services Director] ); Goal: Resident's risk for alteration in skin integrity and infection will be minimized through the next review date; Interventions: Keep resident clean and dry. Provide adult brief unless if resident/family object; Monitor for incontinence frequently, change promptly as needed; Observe for changes in elimination awareness and assess for possible toileting schedule; Offer bedpan or toilet as needed and as resident allows. Review of the CNA (Certified Nursing Assistant) Flow Sheet for Bowel and Bladder Elimination dated 1/6-19/23) documented the resident was always incontinent of bowel. Interview with the Central Supply Clerk on 1/20/23 at 9:00 AM. She stated, I go around and place the supplies in the residents' rooms. The one who wears the pull ups, I place one package in their closet, twice a week. I check the closets twice a week, Mondays, and Thursdays to make sure they have pull-ups. The residents that are alert, have told me that the CNAs (Certified Nursing Assistants) will come in their rooms and take the whole pack of pull ups out and take them to another resident's room. I have told them to say something and speak up, to let someone know that they shouldn't take them. There is no excuse, that there are no pull ups in the resident's room because they can come to me and ask for more pack of pull ups and if I am not in the supply room, they can come in here and get the package of pull ups. I also, have another room upstairs, that contains supplies and pull-up packages. Interview with Staff E, a Licensed Practical Nurse (LPN) on 1/20/22 at 10:29 AM. He stated, She is alert and oriented time one with mild confusion. She is total dependence for toileting. She wears adult briefs. The adult briefs are kept in her closet, and they are replenished as needed. Interview with the Director of Nursing on 1/20/22 at 12:28 PM. He stated, The resident is incontinent of bowel and bladder. If they provide incontinence care, they should have the supplies available to provide it. The staff can go to the supply room and get the supplies that are needed for the resident. There needs to be a stack of supplies in the resident's closet for them to use. 105120 Page 7 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) Initial observation and interview with Resident #514 on 1/17/2023 at 12:30 PM revealed the resident sitting up in a wheelchair in his room, wearing glasses and watching TV. Nasal cannula noted on the resident's bed, and he was not wearing it. Resident #514 revealed he was not using /wearing the nasal cannula. Second observation of Resident #514 on 1/18/2023 at 9:22 AM revealed the resident sitting in a wheelchair in his room, wearing glasses and watching TV. The nasal cannula was noted on the resident's bed, and he was not wearing it. Third observation of Resident #514 on 1/20/2023 at 8:05 AM revealed the resident sitting up in bed, watching TV and wearing glasses. The resident's Nasal cannula was noted on the resident's bed and the resident was not wearing it. Record review of the Demographic Face Sheet for Resident #514 documented the resident was admitted on [DATE] with diagnoses to include end stage renal disease, dependence on renal dialysis, anemia, heart failure, atrial fibrillation, insomnia, major depressive disorder, and hypertension. Review of the Minimum Data Set (MDS) 5-Day Assessment for Resident #514 dated 1/07/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make his needs known. The resident required extensive assistance with one-person physical assist for ADLs (Activities of Daily Living) and required oxygen therapy. Review of the Physician's Orders Sheet (POS) dated January 2023 for Resident #514 documented Oxygen at 2 L (liter)/min (minute) via nasal cannula continuously every shift. The order start date was 1/11/2023. Observations revealed resident #514 was not wearing the nasal cannula continuously. Review of the Treatment Administration Record (TAR) dated 01/11/ 2023 to 01/19/2023, for Resident #514 documented the resident received continuous oxygen each day. Observations revealed resident #514 was not wearing a nasal cannula continuously on 01/17/2023 to 01/20/ 2023. Review of Resident's #514's baseline care plan dated 1/10/2023 documented the resident was to receive continuous oxygen. Review of Resident's #514's Respiratory care plan dated 1/19/2023 documented: Focus: Resident has diagnosis of CHF, Chronic Pulmonary Edema and is at risk for respiratory complications (written 1/19/2023); Goal: Resident will maintain optimal breathing and not have any s/s (signs/symptoms) of respiratory distress or infections through next review dated; Interventions: Monitor O2 sats (saturation) as needed and per facility protocol; Oxygen via nasal cannula continuously. Interview and record review with Staff D, a Registered Nurse (RN), Unit Manager on 1/20/23 at 10:12 AM. She stated, He has an order for oxygen PRN (as needed), and it was changed on yesterday 1/19/2023. Before that he had an order for continuous oxygen order. When I went into his room, he was not wearing the nasal cannula. He should have been wearing the nasal cannula. Record review with Staff D documented the respiratory care plan had been changed to have oxygen available if ordered and as needed late in the afternoon on 1/19/2023. Interview and record review with Staff E, a Licensed Practical Nurse (LPN) on 1/20/2023 at 10:32 AM. Staff E stated, He had an order for continuous oxygen, but he was not wearing it. The order was 105120 Page 8 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0656 changed to PRN for the oxygen on yesterday. Level of Harm - Minimal harm or potential for actual harm Interview and record review with Staff C, a Licensed Practical Nurse (LPN) MDS Coordinator on 1/20/2023 at 11:36 AM. She stated, On his previous care plan for COPD, he had continuous oxygen. It was changed this morning to oxygen as needed. Residents Affected - Few Interview and record review with the DON (Director of Nursing) on 1/20/2023 at 12:33 PM. He stated, His interim care plan documents he needed continuous oxygen. His baseline care plan was written on 1/10/2023 and documented initial goals was continuous oxygen. The POS for January 2023 documented O2 (oxygen) at 2 L/min (liter)/min (minute) via nasal cannula continuously every shift (Start 1/11/23). 3) On 01/18/2023 at 11:01 AM, Resident # 70 was observed lying in bed with eyes closed. The resident was receiving oxygen therapy via nasal cannula, the concentrator was set at 2 liters per minute (LPM). (Photographic evidence). Record review of admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnoses included, but were not limited to, End Stage Renal Disease; Pneumonia, Unspecified Organism; Type 2 Diabetes Mellitus without Complications; Dependence on Renal Dialysis. Review of the active physician's orders documented ordered oxygen at 3 liters per minute via nasal cannula continuously every shift with start date 12/19/2022. On 01/18/2023 at 1:45 PM, Resident#70 was observed in bed sleeping. The oxygen concentrator was set at 2 LPM. No distress noted. Record review of Medicare 5 days Minimum Data Set (MDS) Section C for cognitive status dated 01/07/2023 revealed the Brief Interview of Mental Status (BIMS) Summary Score was 10 out of 15 meaning the resident moderately impaired cognition. Section G for functional status dated 01/07/2023 revealed the resident needed extensive assistance with one-person physical assistance for bed mobility, dressing, eating, toilet use and personal hygiene. The resident needed total dependence with one-person physical assistance for transfer and locomotion. Section O for special treatments revealed the resident was receiving oxygen treatment and dialysis. Record review of Care Plan initiated on 12/20/2022 and revised on 01/11/2023 revealed the resident is at risk of COVID-19 Exposure and at risk for respiratory complications. Goal: The resident will maintain airways and oxygen exchange as evidence of normal oxygen saturation and breathing pattern. Interventions: Administer oxygen as ordered. Administer medications as ordered by physician. Monitor oxygen saturation as ordered or as needed. Interview with Staff B, a Licensed Practical Nurse (LPN) on 01/20/23 at 12:16 PM, revealed the resident was transferred to the hospital due to the need of blood transfusion due to low hemoglobin. Staff B reported it is in charge of checking the oxygen concentrator every day when the shift started. Staff B stated that she stated she did not realize the oxygen concentrator level was not set up as ordered by the physician. 105120 Page 9 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (Resident #73) out of one resident reviewed for bowel and bladder incontinence received adequate incontinence care. Resident #73 did not receive incontinence care for over three hours. Incontinent products such as adult briefs were not readily available. The facility failed to ensure that residents requiring incontinent care had the needed supplies and were being checked and changed as needed in a timely manner based upon the resident's voiding pattern to meet professional standards of practice. This deficient practice has the potential to affect 73 residents receiving bowel incontinence care out of 111 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's Activities of Daily Living (ADL) Policy and Procedure (implemented 11/28/2017, reviewed 10/26/2022) documented the following: Policy Statement: The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the residents' ability to 3) Toilet. Policy Explanation and Compliance Guidelines: 2) The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment; 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 with Resident #73 on 1/17/23 at 10:14 AM revealed the resident sitting up in bed, watching television (TV) and wearing glasses; No odors noted. She stated, I have been sitting in poop since 7:00 AM. I pressed the call light, they came in here, removed the diapers from my room for another room and never changed me. I want to be changed because I don't want my [private part] burning. The resident reported that she had been sitting in her feces for more than three hours. Observation on 1/17/23 at 10:19 AM revealed a staff member coming into the resident's room, while Resident # 73 was being interviewed. The staff member was observed placing a package of adult briefs in the resident's closet. Observation revealed Staff F, a Certified Nursing Assistant (CNA) on 1/17/23 at 10:21 AM entering Resident's #73 room. During an interview with Staff F, CNA, she stated, I came in here early this morning because of the light on. I told her I would be back. I was waiting on them to bring [adult briefs] in. They just brought the [adult briefs] in. I can change her now. Staff F further revealed that the resident pressed the call light at 7:00 AM, asking to be changed but she did not change the resident because breakfast was being served and she did not have any adult briefs in the resident's room. Record review of the Demographic Face Sheet for Resident #73 documented the resident was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, hypertension, anxiety disorder, insomnia, and morbid obesity. Review of the Minimum Data Set (MDS) 5-Day Assessment for Resident #73 dated 12/08/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 09 out of 15 indicating mild cognitive impairment and the resident was able to make her needs known. The resident required 105120 Page 10 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few total dependence with one-person to physical assist for toileting and extensive assistance with one-person physical assistance for ADLs (Activities of Daily Living). Review of the Physician's Orders Sheet (POS) dated January 2023 for Resident #73 documented the resident received Lyrica cap (capsule) 50mg (milligrams) 1 cap PO (by mouth) TID (three times a day) for nerve pain, Trazodone HCL tab (tablet) 100 mg 1 tab PO HS (at night) for insomnia, Furosemide tab 40 mg tab 1 tab PO one time a day for hypertension, Buspirone HCL tab 10mg tab 1 tab PO TID for anxiety and record bowel movement (BM) every shift S-small, M-medium, L-large, 0-No BM (Start date 11/30/22). Review of Resident's #73's ADL care plan dated 12/01/22 documented: Focus: Resident has ADL self-care deficit, Toilet use: Total; Goal: Resident will maintain a sense of dignity by being clean, dry, odor free and well-groomed and risk for further decline. Will be minimized through next review date; Interventions: Assist with ADLs as needed. Review of Resident's #73's Bladder and Bowel care plan dated 12/01/22 documented: Focus: Resident is always incontinent of B&B (Bladder and Bowel) functions r/t (related to) functional decline and is at risk for alteration in skin integrity and infection. Sometimes, the resident states that she is soiled, and she is actually dry (written 12/01/22; revised 1/17/23 to include [Sometimes, the resident states that she is soiled, and she is actually dry by Social Services Director]); Goal: Resident's risk for alteration in skin integrity and infection will be minimized through the next review date; Interventions: Keep resident clean and dry. Provide adult brief unless if resident/family object; Monitor for incontinence frequently, change promptly as needed; Observe for changes in elimination awareness and assess for possible toileting schedule; Offer bedpan or toilet as needed and as resident allows. Review of the CNA (Certified Nursing Assistant) Flow Sheet for Bowel and Bladder Elimination dated 1/6-19/23) documented the resident was always incontinent of bowel. Interview with the Central Supply Clerk on 1/20/23 at 9:00 AM. She stated, I go around and place the supplies in the residents' rooms. The one who wears the pull ups, I place one package in their closet, twice a week. I check the closets twice a week, Mondays, and Thursdays to make sure they have pull-ups. The residents that are alert, have told me that the CNAs (Certified Nursing Assistants) will come in their rooms and take the whole pack of pull ups out and take them to another resident's room. I have told them to say something and speak up, to let someone know that they shouldn't take them. There is no excuse, that there are no pull ups in the resident's room because they can come to me and ask for more pack of pull ups and if I am not in the supply room, they can come in here and get the package of pull ups. I also, have another room upstairs, that contains supplies and pull-up packages. Interview with Staff E, a Licensed Practical Nurse (LPN) on 1/20/22 at 10:29 AM. He stated, She is alert and oriented time one with mild confusion. She is total dependence for toileting. She wears adult briefs. The adult briefs are kept in her closet, and they are replenished as needed. Interview with the Director of Nursing on 1/20/22 at 12:28 PM. He stated, The resident is incontinent of bowel and bladder. If they provide incontinence care, they should have the supplies available to provide it. The staff can go to the supply room and get the supplies that are needed for the resident. There needs to be a stack of supplies in the resident's closet for them to use. 105120 Page 11 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to 1) ensure one (Resident #514) out of three residents reviewed for oxygen treatment received continuous oxygen treatments and 2) one resident (Resident #70) received the correct amount of oxygen out of three residents reviewed for oxygen treatment. This has the potential to affect 14 residents receiving respiratory treatment out of 111 residents residing in the facility at the time of this survey. Residents Affected - Few The findings included: 1) Record review of the Oxygen Administration Policy and Procedure (implemented 11/28/2017, reviewed 11/28/2020) documented the following: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the residents' goal and preferences. Policy Explanation and Compliance Guidelines: 1) Oxygen is administered under orders of a physician; 3) Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy; 4) The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. Initial observation and interview with Resident #514 on 1/17/23 at 12:30 PM revealed the resident sitting up in in a wheelchair in his room, wearing glasses and watching TV. Nasal cannula noted on the resident's bed and he was not wearing it. He revealed he wasn't wearing the nasal cannula. Second observation of Resident #514 on 1/18/23 at 9:22 AM revealed the resident sitting in a wheelchair in his room, wearing glasses and watching TV. Nasal cannula noted on the resident's bed and he was not wearing it. Third observation of Resident #514 on 1/20/23 at 8:05 AM revealed the resident sitting up in bed, watching TV and wearing glasses. Nasal cannula noted on the resident's bed and he was not wearing it. Record review of the Demographic Face Sheet for Resident #514 documented the resident was admitted on [DATE] with a diagnoses to include end stage renal disease, dependence on renal dialysis, anemia, heart failure, Atrial fibrillation, insomnia, major depressive disorder and hypertension. Review of the Minimum Data Set (MDS) 5-Day Assessment for Resident #514 dated 1/07/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 15 out of 15 indicating no cognitive impairment and the resident was able to make his needs known. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and required oxygen therapy. Review of the Physician's Orders Sheet (POS) dated January 2023 for Resident #514 documented Oxygen at 2 L (liter)/min (minute) via nasal cannula continuously every shift. The start order date was 1/11/23. Observations revealed resident #514 was not wearing the nasal cannula continuously. Review of the Treatment Administration Record (TAR) dated January 11-19, 2023, for Resident #514 documented the resident received continuous oxygen each day. Observations revealed resident #514 was not wearing a nasal cannula on January 17-20, 2023, continuously. 105120 Page 12 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident's #514's baseline care plan dated 1/10/2023 documented the resident was to receive continuous oxygen. Review of Resident's #514's Respiratory care plan dated 1/19/23 documented: Focus: Resident has diagnosis of CHF, Chronic Pulmonary Edema and is at risk for respiratory complications (written 1/19/23); Goal: Resident will maintain optimal breathing and not have any s/s (signs/symptoms) of respiratory distress or infections through next review dated; Interventions: Monitor O2 sats (saturation) as needed and per facility protocol; Oxygen via nasal cannula continuously. Interview and record review with Staff D, Registered Nurse (RN), Unit Manager on 1/20/23 at 10:12 AM. She stated, He has an order for oxygen PRN (as needed) and it was changed on yesterday 1/19/23. Before that he had an order for continuous oxygen order. When I went into his room, he was not wearing the nasal cannula. He should have been wearing the nasal cannula. Record review with Staff D documented the respiratory care plan had been changed to have oxygen available if ordered and as needed late in the afternoon on 1/19/23. Interview and record review with Staff E, Licensed Practical Nurse (LPN) on 1/20/23 at 10:32 AM. He stated, He had an order for continuous oxygen but he was not wearing it. The order was changed to PRN for the oxygen on yesterday. Interview and record review with Staff C, Licensed Practical Nurse (LPN) MDS Coordinator on 1/20/23 at 11:36 AM. She stated, On his previous care plan for COPD, he had continuous oxygen. It was changed this morning to oxygen as needed. Interview and record review with the DON (Director of Nursing) on 1/20/23 at 12:33 PM. He stated, His interim care plan documents he needed continuous oxygen. His baseline care plan was written on 1/10/23 and documented initial goals was continuous oxygen. The POS, January 2023 documented O2 (oxygen) @ (at) 2 L/min (liter)/min (minute) via nasal cannula continuously every shift (Start 1/11/23). 2) Observation of Resident # 70 on 01/18/2023 at 11:01 AM revealed the resident lying in bed with eyes closed. The Resident was receiving oxygen therapy. The oxygen concentrator level was set at 2 liters per minute (LPM). (Photographic evidence). Record review of admission Record revealed Resident #70 was admitted to the facility on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnoses included, but were not limited to, End Stage Renal Disease; Pneumonia, Unspecified Organism; Type 2 Diabetes Mellitus without Complications; Dependence on Renal Dialysis. Review of the active physician's orders documented ordered oxygen at 3 liters per minute via nasal cannula continuously every shift with start date 12/19/2022. On 01/18/2023 at 1:45 PM, Resident#70 was observed in bed sleeping. The oxygen concentrator was set at 2 LPM. No distress noted. Review of Medicare 5 days Minimum Data Set (MDS) Section C for cognitive status dated 01/07/2023 revealed the Brief Interview of Mental Status (BIMS) Summary Score was 10 out of 15 meaning the resident moderately impaired cognition. Section G for functional status dated 01/07/2023 revealed the resident needed extensive assistance with one-person physical assistance for bed mobility, dressing, 105120 Page 13 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eating, toilet use and personal hygiene. The resident needed total dependence with one-person physical assistance for transfer and locomotion. Section O for special treatments revealed the resident was receiving oxygen treatment and dialysis. Record review of Care Plan initiated on 12/20/2022 and revised on 01/11/2023 revealed the resident is at risk of COVID-19 Exposure and at risk for respiratory complications. Goal: The resident will maintain airways and oxygen exchange as evidence of normal oxygen saturation and breathing pattern. Interventions: Administer oxygen as ordered. Administer medications as ordered by physician. Monitor oxygen saturation as ordered or as needed. Interview with Staff B, a Licensed Practical Nurse (LPN) on 01/20/23 at 12:16 PM, revealed the resident was transferred to the hospital due to the need of blood transfusion due to low hemoglobin. Staff B reported it is in charge of checking the oxygen concentrator every day when the shift started. Staff B stated that she stated she did not realize the oxygen concentrator level was not set up as ordered by the physician. Record review of the facility's Policies and Procedures for Oxygen Administration dated 11/28/2017 revealed the Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: 1- Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Record review of Policies and Procedures for Admission, Orders and Processes implemented on 11/28/2017 by Corporate Director of Clinicals revealed Policy: in accordance with Federal Regulation 483.20 (a), a physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide orders for the resident's immediate care and needs. This is done to ensure each resident receives necessary care and services upon admission. 105120 Page 14 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain communication with hospice to ensure continuation of care for 1 (Resident #79) out of 2 residents receiving hospice care, as evidenced by no updated hospice communication notes available in Resident #79's medical records. There were 111 residents residing in the facility at the time of this survey. The Findings Included: During observation on 1/17/23 at 8:50 AM Resident #79 was observed in bed, Tube feeing was running at 70 milliliters per hour (ML per Hr.), flush orders 30 ML per hr., Oxygen concentrator and nebulizer in room. On 01/18/23 at 08:36 AM Resident #79 observed in bed asleep, call light on bed Tube Feeding running at correct rate, no distress noted. During observation on 01/19/23 at 10:08 AM Resident#79 in bed laying down, eyes open, no distress noted, Tube Feeding running at correct rate. Review of the medical records for Resident #79 revealed the most recent documentation from Hospice being on site for Resident #79 were a Hospice Aid Report dated 1/10/23 and 1/09/23, a Hospice social worker report dated 12/21/22 and an Initial Comprehensive assessment dated [DATE]. Further review of the medical records for Resident #79 revealed the resident was admitted to the facility on [DATE] and admitted to hospice on 11/17/22. Clinical diagnoses included but not limited to: Cerebral Atherosclerosis. Review of the Physician's Orders Sheet for January 2023 revealed Resident #79 had orders that included but not limited to: [Hospice Company] care as of 11/17/22, Diagnosis: Cerebral Atherosclerosis and Do Not Resuscitate (DNR). Record review of Resident #79's Significant change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented- Brief Interview for Mental Status Score-Unable to determine. Section G for Functional status documented-Total Dependence for Activities for Daily Living (ADLs). Section J for Health conditions documented the resident received no scheduled or as needed pain medication regimen in the last 5 days. Section H for Bowel and Bladder documented the resident is always incontinent of bowel and bladder. Section K for Nutritional Status documented resident had weight gain and is not on a prescribed weight gain regimen, resident is on tube feeding. Section O for special treatments documentedResident received hospice care in the last 14 days. Record review of Resident #79 's Care Plans Reference Date 11/18/22 documented: The resident is on [company name] hospice care with terminal diagnosis of Cerebral Atherosclerosis. The resident is a DNR. Interventions include: The resident's risk for alteration in comfort will be minimized and staff will continue to provide dignity, comfort, and support throughout the dying process, apply the DNR bracelet, encourage resident and family to express their feelings openly, generate telephone order for the DNR, honor DNR order, maintain resident comfort and dignity, notify Hospice of any changes in condition, notify Medical Doctor (MD)of any changes in condition, observe for sign and symptoms of 105120 Page 15 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pain and discomfort and medicate as ordered, Place red dot on the medical record and ensure that copies of the DNR are noted on the medical record, provide ADL needs as tolerated and as needed and the initial certificate of terminal illness is to be placed on the medical record. Interview on 01/19/23 at 11:53 AM with Registered Nurse (RN) Station 2 Unit manager, Staff A, stated hospice visits the resident weekly, the hospice nurse communicates with me verbally and put the information in the hospice notes, we have a hospice binder where the hospice nurse leaves the notes in before they leave the facility. The resident started on vitas hospice on 11/17/22. On 01/19/23 at 12:00 AM, Staff A stated she will call hospice to see where the hospice notes are. On 01/19/23 at 12:23 PM Staff A stated the hospice nurse called and will be faxing the hospice notes to the facility shortly. On 01/20/23 at 8:00 AM, the Director of Nursing (DON) stated he spoke with hospice, and they will be sending the nurse to the facility today with all the communication notes. The Social Services Director (SSD) is responsible for the coordination of care with hospice. I will let you talk with her about what we are going to implement with hospice moving forward. Interview on 01/20/23 at 10:00 AM, the Hospice Registered Nurse stated: I am the hospice nurse for this facility since January 2023, this resident is nonverbal, stable, he has a peg tube and a rash on the skin he is being treated for currently, he is on hospice primarily for cerebral infarction. I visit this resident once a week normally, unless there is sometime going on, last week his Jackson Pratt (device is used to drain bodily fluids that might collect under or near the incision) post-surgical procedure, from the right upper section came out, he went to the hospital and it was not reinserted, they changed the peg tube instead. The hospice aids should be coming to the facility 3 times a week for patient care and ADLS. When I enter the facility, I talk with the CNAs and nurses of the hospice residents to get a report on the residents, then I visit the residents, I do an assessment, and follow up with the nurses before I leave the facility for the day. I communicate with the nurses and the unit managers. We don't have any communications note that we leave with the facility, but I have my notes that I take back to the office and file. They have a sign in log at the entrance of the facility I fill out when I visit that can show when the last time was I was at the facility. The last time I was here in the facility to see the resident was on 1/18/23 and I spoke with the floor nurse of the resident. Moving forward, the last page of my visitation notes, I will be leaving with the facility to document patient care plan and last time resident was seen by hospice. Interview on 01/20/23 at 01:22 PM, the Social services Director (SSD) stated: I will accept the responsibility of making sure that when any hospice personnel visit the facility, they leave some form of communication with us before they exit. When the social worker from hospice comes to the facility, she comes to see me to inquire about the needs of the hospice residents, we invite the hospice team to our quarterly care plan meetings, I send out an invitation and call them as a friendly reminder to make sure they participate in the care plan meetings for their residents. Review of the facility's policy and procedures titled, Hospice Services and Facility Agreement revision date 11/28/2017 states: Policy Explanation and Compliance Guidelines: 3. If hospice care is furnished in the facility through an agreement, the facility will: Ensure that the hospice services meet professional standards and principle that apply to individuals providing services in the facility, and to the timeliness of the services. 105120 Page 16 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0849 4. The written agreement(s) will set out at least the following: Level of Harm - Minimal harm or potential for actual harm a. The services the hospice will provide. b. The hospice's responsibilities for determining the appropriate hospice plan of care. Residents Affected - Few c. The services the facility will continue to provide based on each resident's plan of care. d. A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. 105120 Page 17 of 18 105120 01/20/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview the facility failed to demonstrate Quality Assurance and Performance Improvement (QAPI) implemented effective plan of actions to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 645- Preadmission Screening and Resident Review (PASRR) and F 656- Develop/Implement Comprehensive Care Plans. These repeated deficient practices have the potential to increase the risk of negative resident outcomes and to affect all 111 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 08/27/2021 the facility was cited F 645 due to the facility's failure to ensure completion of a level II Preadmission Screening and Resident Review (PASRR) for two out of three residents. The facility was also cited F 656 for failure to Develop/Implement Comprehensive Care Plans related to pressure ulcers. During this survey with exit dated 1/20/2023 the facility was cited F 645 and F 656. Record review of the facility's policy revealed: It is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-drive QAPI program that focuses on indicators of the outcomes of care and quality of life as per the Federal Regulation $483.75(a) which is to maintain documentation and demonstrate evidence of it ongoing QAPI program that meets the requirements of the section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective action or performance improvement activities. $483.75(a) Present its QAPI plan to State Survey Agency of Federal surveyor at each annual recertification survey and upon request during any other survey and CMS upon request; and During an interview on 01/20/2023 at 14:35 PM, the Director of Nursing (DON) revealed that the Quality Assessment and Assurance Committee (QAA) meets every third Friday of every month. The Administrator stated that the QAA Committee is comprised of the following members: Director of Nursing Services, Medical Director, Nursing home administrator, Unit Managers, Dietitian, Food Service Director, Social Worker Director, Activities Director, Business Office Manager, House Keeping Director, Maintenance Director, Human Resources, Wound Care Nurse, Infection Preventionist, Pharmacy Consultant (If available). Every month during the meeting they go back with the plan of correction to make sure that they are up to date or if they need to modify it. If there is something that they need to modify, they go over with the team and they create another group to address that issue. When there is a deviation, they look at the [NAME] report that lets them know of any issues in a certain area or let them know that if it goes in a negative way, they look at what they are doing to decide if to change the way that are tracking the QAPI. Once they reach a goal for a certain QAPI they give it about 3 months and will drop it once it reached the goals sets forward. If needed, we will continue for another 3 months. 105120 Page 18 of 18