Health inspection·June 20, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain orders that accurately reflected code status for one (Resident #39) out of two residents reviewed for Advanced Directives. The findings included: Resident #39 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly Minimum Data Set, dated [DATE], Resident #39 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #39's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Depression, difficulty in walking, Unsteadiness on feet, Lack of Coordination, Muscle weakness, History of falling, Idiopathic pulmonary hemosiderosis, Personal history of disease of the circulatory system. Review of the resident's electronic health record revealed that there was no determination made regarding a code status for the resident. During an interview, on [DATE] at 9:02 AM, with Staff L, Unit Manager, when asked about the code status not being in Resident #39's electronic health record, the Unit Manager stated, then we have to find out. Maybe it is not signed or might have been rescinded. During an interview, on [DATE] at 10:29 AM, with Staff M, Assistant Social Worker, when asked about the responsibility related to admissions and putting in Code Status, If I become aware of the status not being there, I will inform them (admissions) or my Supervisor. She (Resident #39) was here before I came here. it is usually on the face sheet. She is not a DNR, we usually get the information from the family, we get the order from the doctor for the DNR. During an interview, on [DATE] at 11:12 AM, with the Admissions Director, when asked about the procedure for ensuring code status is determined and an order is obtained to reflect the code status, the Admissions Director replied, Social Services (SS) does the Advanced Directives. I ask on admission for living will, POA (Power Of Attorney) I ask them, but I don't put them in. If they are DNR (Do Not Resuscitate), I ask them for a copy of it. I refer to the Director of Nursing (DON) and SS if Advanced directives for full code and DNR are not established. During an interview, on [DATE] at 11:17 AM with the DON, when asked about the communication regarding the code status of Resident #39, the DON replied, there was a previous DON that took a lot of staff with her. When I heard that some of the residents did not have a code status or order for code Page 1 of 32 105120 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0578 Level of Harm - Minimal harm or potential for actual harm status, I checked everyone in the facility and got orders for the code status. If a patient is a DNR, they have a red arm band that indicates DNR, otherwise they have a green arm band that indicates that CPR should be done. Residents Affected - Few 105120 Page 2 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for Unit #1 (13 resident rooms, 1 community shower room, and beauty salon/dialysis storage room), Unit #2 (13 resident rooms and 1 soiled utility room, and Unit #3 (23 resident rooms, 1 community shower and dining room). The findings included: During the resident screenings conducted by the surveyors on 06/16/2024 to 06/17/2024 and the Environmental Tour conducted on 06/17/2024 at 1:00 PM accompanied with the Administrator and Director of Maintenance, the following were noted, 1) Unit #1: room [ROOM NUMBER]: Room walls damaged and in disrepair, over-bed light cord too short for resident use (W-bed), privacy curtain too short to provide resident with visual privacy (D-bed), bathroom water faucet had a large accumulation of yellow matter, and one of two-bathroom lights not working. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed). room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), and bathroom water faucet had a large accumulation of yellow matter. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), exterior surface of over-bed table was heavy worn and exposed wood, exterior of bathroom door heavily damaged and in disrepair, and bathroom toilet requires re-caulking to the floor. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), bathroom door frame rust laden, exterior surface of over-bed tables (2) heavily worn, bathroom water faucet had a large buildup of yellow matter, one out of two-bathroom lights not working, and Right brake of wheelchair not working for resident (W-bed). room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), privacy curtain soiled and stained (1/2), room base baseboards damaged and in disrepair, room entry door damaged and in disrepair. room [ROOM NUMBER]: Bathroom water faucet had a large accumulation of yellow matter. room [ROOM NUMBER]: Room walls damaged and in disrepair, exterior of over-bed tables (20 heavily worn and exposed wood, air-conditioning filter was dirt and dust laden, broken wall electrical cover, privacy curtain too short to provide resident with visual privacy (D-bed). room [ROOM NUMBER]: Bathroom emergency pull cord too short (more than 4: from floor). and privacy curtain too short to provide resident with visual privacy (D-bed). room [ROOM NUMBER]: bathroom water faucet had a large accumulation of yellow matter. 105120 Page 3 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]: Wall mounted television not working/no reception (D-bed - resident complaint), air-conditioning filter dust and dirt laden, exterior of over-bed table (1) heavily worn, room walls damaged and in disrepair, exterior of room chair (1) stained. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), exterior of over-bed table (1) heavily worn, bathroom floor soiled and large black stains, privacy curtains soiled and stained, and cable television wire hanging down and not properly attached to the wall. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (A & B beds), air-conditioning filter was dirt and dust laden, bathroom emergency pull cord was tied around the wall handrail, and room walls damaged and in disrepair. Community Shower: Entry door frame rust laden. Beauty Salon: Room was being used for dialysis supply storage and hair salon and noted to have large balls of hair accumulation around the room floor with clean dialysis supplies, soiled equipment (brooms and dust pans stored in middle of the room, clean dialysis supplies stored on wooden pallets and floor area was heavily soiled underneath could not be properly cleaned, dialysis staff noted to eat their meals in the room and interior of staff room refrigerator was heavily soiled and stained. 2) Unit #2: room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, damaged/broken room base boards, large black stains to room floor, bathroom pull cord too long and resting on the floor, bathroom walls soiled and stained, bathroom door damaged and in disrepair, room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, window curtain broken and will not close, and bathroom door opening handle was falling off of the door. room [ROOM NUMBER]: strong urine odor throughout the room. The bathroom floor, ceiling and walls noted to have a build-up of black mold type matter, bathroom entry door heavy damaged and in disrepair, one of two-bathroom lights not working, bathroom base boards missing, room [ROOM NUMBER]: Strong urine odor throughout the room, and bathroom floor heavily soiled and stained. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, and 1 of 3 dresser drawers do not shut properly. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, room floor noted to have numerous and large black stains, and room floor tiles (10) cracked). room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, oxygen concentrator (A-bed) filter was dirt/dust laden, room floor had numerous large black stains, 105120 Page 4 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0584 bathroom floor had black stains throughout,, and broken window blinds. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy Residents Affected - Some room [ROOM NUMBER]: Privacy curtain too short to promote resident with visual privacy, bathroom entry door damaged and in disrepair, bathroom floor had numerous black stains throughout, bathroom toilet seat was loose, oxygen concentrator filer was dirt/dust laden, room floor numerous large black stains. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, oxygen concentrator missing filter, bathroom numerous black stains, IV poor numerous areas of dried brown matter, bathroom toilet seat was loose, room floors and walls damaged and in disrepair. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy. Soiled Utility Room: Specimen refrigerator interior and exterior was rust laden, and heavy ice buildup with the cavity of the unit. Unit #3: Nurses Station: Floor area within and around the front of the station noted to have numerous large black stains, and 3/3 of chair noted to be torn and stained. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, rooms walls damaged, and in disrepair, and room floor soiled and stained. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and bathroom toilet seat was loose. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, bathroom floor soiled and stained, toilet requires re-caulking to the floor, and exterior of over-bed table (A-bed) was worn with exposed wood splinters. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absence of a window curtain. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absence of window curtain or blinds. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and room floor soiled and had numerous black stains. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absent window curtain, bathroom emergency lull cord wrapped around the wall mounted handrail, no over-bed light cord (D & W Bed), and one of two-bathroom lights not working. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absent window curtain. 105120 Page 5 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absent window curtain. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, window blinds broken and do not operate, exterior of room closet damaged and in disrepair, no over-bed light cord (W-bed), bathroom toilet bowl soiled and stained, and exterior of over-bed table (W-bed) worn with exposed wood. room [ROOM NUMBER]: Privacy curtain (A & B-beds) was to short and did not promote resident privacy, and two of 3-bathroom lights not working). room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, absent window curtain, bathroom floor soiled and numerous black stains, portable commode seat handles were cracked, and one of 3-bathroom lights were not working. room [ROOM NUMBER]: Privacy curtain (A & B-beds) was to short and did not promote resident privacy, room floor soiled with numerous large black stains, exterior of bathroom door had numerous large black scuff markings, room wall vent noted to be dirt/dust laden, and absence of over-bed light cord (W-bed). room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, absent window curtain, exterior of over-bed light (W-bed) was rust laden, bathroom door handle broken and loose, and bathroom floor soiled had large black stain areas. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy. room [ROOM NUMBER]: Privacy curtain (A, B, and C-beds) was to short and did not promote resident privacy, room ceiling tiles (3) stained yellow in color, room floor soiled and black stains, bathroom floor numerous black stains, bathroom sink basin black stains, and television cable wire not properly attached to wall and hanging down off the wall. room [ROOM NUMBER]: Privacy curtain (A, B and C-beds) was to short and did not promote resident privacy, room floor numerous large black stains, absence of window curtain, bathroom toilet seat loose, room walls damaged and in disrepair. Community Shower: Wall vent dirt/dust laden. Nursing Supply Closet: Numerous resident care supplies stored directly on the soiled floor. Dining Room: Room floor soiled and stained, and one of five ceiling lights not working. On 06/20/24 a meeting was conducted with the Administrator to confirm the housekeeping/maintenance issues noted from 06/16-18/24. The administrator stated she was aware of the issues located on the Unit #1, #2, and #3 Units. During the meeting it was also noted that each of the nurses stations located on the units (3) have a maintenance log that staff are required to date and document and housekeeping/maintenance issues. Further stated that maintenance staff check the logs daily, however, are not documenting their issues on the maintenance logs. 105120 Page 6 of 32 105120 06/20/2024 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 interviews and record reviews the facility failed to ensure accuracy of medical personnel title for 1 of 29 sampled residents (Resident #32). Residents Affected - Few The findings included: Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnosis including: Disorganized Schizophrenia, Other Psychotic Disorder Not Due to a Substance or Known Physiological Condition and Major Depressive Disorder. Review of the Minimum Data Set for Resident #32 dated 03/27/2024 revealed in section C for Cognitive Pattern documented a Brief Interview of Mental Status score of 15 out of indicating a cognitive response. During an interview conducted on 06/20/2024 at 9:45 AM with the Director of Nursing (DON) revealed she has worked at the facility since beginning of May 2024. When asked when Resident #32 was last seen by a physician, she reported it was 12/28/2023 by Staff G (later discovered to be a Nurse Practitioner). When asked what kind of physician it was that had seen the resident on 12/28/2023, if it was the primary physician or some other type of physician, she said she was not familiar with all of the physicians yet since she is still fairly new to the facility, it was revealed she did not know. She contacted the admission Director to pull the physician's license who had seen the resident on 12/28/2023. When the license was provided to the DON, she acknowledged Staff G who saw the resident on 12/28/2023 was a Nurse Practitioner and not entering the medical personnel title into the facility's electronic system, she said she believes it is the admission Director who also verifies medical personnel credentials. During an interview conducted on 06/20/2024 at 10:00 AM with the admission Director who reported she is the one to verify credentials for the Physicians, PAs (Physician Assistants), and NPs (Nurse Practitioners) up until 6 months ago she was the one who entered them into the facility's electronic system including their title. The admission Director reported now she believes it is the DON who enters the information. The admission Director was asked about the Physician's Note for Resident #32 dated 12/28/2023 electronically signed by Staff G Nurse Practitioner (NP) but identified in the EMR (Electronic Medical Records) as a physician, the admission Director acknowledged Staff G is not a physician. Review of the Physician's Notes for Resident #32 revealed on 12/28/2023 the Physician's Note was 105120 Page 7 of 32 105120 06/20/2024 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 observations, interviews and record reviews, the facility failed to develop and implement care plans for the use of bed rails for 3 of 3 residents reviewed for bed rails, Residents #54, 5, and 120. The facility failed to develop and implement a care plan for a urinary catheter for 1 (Resident #7) of 1 resident reviewed for catheter. The findings included: The facility's policy, Proper use of Bed Rails, implemented 05/01/2023, documented: Ongoing Monitoring and Supervision. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan . During an interview, on 06/20/2024 at 1:50 PM, with Staff N, MDS (Minimum Data Set) Coordinator, when asked about the lack of care plan for Resident #54's bed rails, the MDS Coordinator stated that Restorative was responsible for initiating care plans for bed rails. During an interview, on 06/20/2024 at 1:57 PM, with Staff O, LPN (License Practical Nurse) /Restorative Nurse, when asked about care plans that the Restorative staff are responsible for, Staff O replied, falls, ADLs, (Activities Of Daily Living) incontinence - I am in the middle of training in the department. The DON (Director Of Nursing) oversees the restorative program. During an interview, on 06/20/2024 at 2:01 PM, with the DON, when asked about the Restorative staff responsible for care plans, the DON replied, He was just hired for that less than a month ago. 1). Resident #54 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE], Resident #54 had a Brief Interview for Mental Status (BIMS) score of 10, indicating that Resident #54 was 'moderately' cognitively impaired. Resident #54's diagnoses at the time of the assessment included: Hypertension, Parkinson's disease, Malnutrition, Schizophrenia, Mood disorder, Blindness in one eye and low vision in the other eye, Corneal disorder due to contact lens, contracture to right wrist, right hand and left hand. Resident #54's orders included: Pressure reduction mattress with bilateral 1/2 rails for bed mobility and positioning to promote independence - 10/13/2022. Resident requires 2 persons to assist with the use of mechanical lift for transfer - 04/30/2021. Further review of Resident #54's electronic health record revealed that there was no care plan for the rails. On 06/18/2024 at 10:18 AM Resident #54 was observed in bed and was noted to appear highly agitated. The resident was yelling out loud in Spanish and shaking from side to side by grabbing the rails through one of the openings near the top of the rail that went from HOB (Head Of Bed) to approximately the middle of the bed. Resident #54 then was observed on her right side clutching the rail on the residents left side of the bed and was able to pull upper body up while on her side. 105120 Page 8 of 32 105120 06/20/2024 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). Resident #5 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS, dated [DATE], Resident #5 had a BIMS score of 15, indicating the resident was 'cognitively intact'. Resident #5's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Non-Alzheimer's dementia, Seizure disorder, Anxiety disorder, Bipolar disorder, Schizophrenia, Difficulty in walking, Unsteadiness on feet, Lack of coordination, Insomnia, Hereditary and idiopathic neuropathy, Muscle weakness. Resident #5's orders included: Pressure reduction mattress with bilateral 1/2 rails for bed mobility and positioning to promote independence - 12/05/2023. On 06/18/2024 at 9:35 AM, Resident #5 was observed in bed with side rails that extended from the head of the bed to approximately the middle of the bed. It was noted that the rails were covered with a foam material that appeared to be floatation devices (pool noodles) held to the rails using scotch tape. During an interview, on 06/20/2024 at 9:43 AM, Staff L stated, she is alert and oriented and when she has a UTI (Urinary Tract Infection), she gets agitated and confused. She has recurring UTI. at least a couple of times a year. She has been here a long time. Staff L confirmed orders for half rails. Further review of Resident #5's electronic health record revealed that there was no care plan for the use of the bed rails. 3). Resident #120 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS, dated [DATE], Resident #120 had a BIMS score of 10, indicating that Resident #120 was 'moderately cognitively impaired. Resident #120's diagnoses at the time of the assessment included: Hypertension, Non-Alzheimer's dementia, Encephalopathy, Muscle weakness, Unsteadiness on feet, Insomnia. Resident #120's orders included: Pressure reduction mattress with bilateral 1/2 rails for bed mobility and positioning to promote independence - 12/13/2023. Further review of Resident #120's health record revealed that there was no care plan for the use of the bed rails. On 06/17/2024 at 11:29 AM, Resident #120 was observed in her wheelchair to the left side of the bed with rails that extended from the head of the bed to approximately middle of the bed raised with green foam taped to rails that appeared to be floatation devices (pool noodles) held to the rails using scotch tape. An interview was attempted, however the resident was agitated and appeared confused and was providing nonsensible answers to questions. On 06/19/2024 at 9:39 AM, Resident #120 was observed in bed sleeping with rails in raised position and green foam material on the rails. During an interview, on 06/20/2024 at 9:38 AM, with Staff L, when asked about the use of the rails, Staff L replied, she is supposed to have grab bars, the little, short ones that are around the shoulder and they should not be those. She ambulates on her own free will. Sometimes the residents will sleep against it or get a bruise from it (referring to the use of the foam material). 105120 Page 9 of 32 105120 06/20/2024 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 4). Review of the facility's policy titled, Appropriate Use of Indwelling Catheters, dated 05/01/2023, included the following: Policy Explanation and Compliance Guidelines: Item 9. The plan of care will address the use of an indwelling urinary catheter, including strategies to prevent complications. Review of the Nursing Progress notes revealed that on 03/25/2024 Resident #7 had a Urologist appointment located outside of the facility. During the appointment, Resident #7 had a procedure for indwelling catheter placement. Resident #7 returned to the facility with an indwelling catheter and orders for clinical monitoring for signs of upper urinary tract deterioration and/or recurrent UTIs. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #7 had a Brief Interview for Mental Status of 11, which indicated that he was moderately cognitively impaired. Review of Section H revealed that Resident #7 did not have an indwelling catheter. Review of the Care Plan dated 03/27/2024 documented that Resident #7 had incontinence of Bowel functions and at risk for alteration in skin integrity and infection related to the diagnosis neuromuscular dysfunctions, BPH, history of chronic UTI, and Bacteremia. Interventions were to currently take antibiotics for UTI prophylaxis, monitor urine for odor and output and report abnormalities to physician. No care plan nor interventions were noted for an indwelling catheter. An interview was conducted on 06/20/2024 at 1:52 PM with MDS nurse. She stated that the care plans are based on the residents' diagnoses and their problems. She gathers the residents' information from daily clinical meetings, social services, restorative services and the current physician's orders. The MDS nurse stated that Resident #7's indwelling catheter was added to the care plan dated 03/27/2024. Upon review of the Care plan dated 03/27/2024 she noted that the plan of care did not refer Resident #7 having an indwelling catheter nor any interventions or strategies to prevent UTIs. 105120 Page 10 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to apply splint devices as ordered to prevent further decrease in range of motion for 1 of 1 resident reviewed, Resident #39. The findings included: Resident #39 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #39 had a Brief Interview for Mental Status score of 10, indicating that the resident was moderately cognitively impaired. The MDS documented that Resident #39 had bilateral impairments to upper and lower extremities and was dependent upon staff for all activities of daily living (ADLs). Resident #39's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Depression, difficulty in walking, Unsteadiness on feet, Lack of Coordination, Muscle weakness, History of falling, Idiopathic pulmonary hemosiderosis, Personal history of disease of the circulatory system. Resident #39's Orders included: RNP:(R) Knee splint daily for 4 hours daily. May remove for ADLs and skin audit. - every day shift for Contracture Prevention/Management - 07/18/2023 with a start date of 07/19/2023. RNP: (L) knee splint daily for 4 hours daily. May remove for ADLs and skin audit. - every day shift for Contracture Prevention/Management - 07/18/2023 with a start date of 07/19/2023. RNP: (R) elbow extension splint daily for 4 hours. May remove for ADLs and skin audit. - every day shift for Contracture Prevention/Management - 07/18/2023 with a start date of 07/19/2023. On 06/17/2024 at 11:11 AM, Resident #39 was observed up in her wheelchair, while staff was tending to room. It was noted that the resident's right hand was clinched and there was no splint or device noted. On 06/18/2024 at 7:20 AM, Resident #39 was observed in bed sleeping with no device noted. On 06/18/2024 at 9:20 AM, Resident #39 was observed in bed and awake. When the resident was asked about the use of splints or devices, Resident #39 did not provide a response. It was determined that the resident was not interviewable. On 06/18/2024 at 12:08 PM, Resident #39 was observed up in her wheelchair and no brace noted. On 06/18/2024 at 1:44 PM, Resident #39 was observed in her wheelchair in activities with no braces noted. On 06/19/2024 at 6:44 AM, Resident #39 was observed in bed sleeping with no braces noted. During an interview, on 06/19/2024 at 6:58 AM, with Staff P, LPN, when asked about the use of splints or devices for Resident #39, Staff P replied, she is not contracted when asked about the resident's right hand being contracted, Staff P replied, yes she is. During an interview, on 06/19/2024 at 9:28 AM, with Staff O, LPN/Restorative Nurse, when asked about Resident #39 's contractures, Staff O replied, She is contracted, she has contractures, They 105120 Page 11 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0688 Level of Harm - Minimal harm or potential for actual harm (referring to splints and braces) are to avoid further contraction and they are care planned. When asked about staff applying the devices, Staff O replied, They do their rounds downstairs and are up here by 8:30 AM for rounds (referring to the restorative CNAs), and that is when they put the braces on prior to ADLs. Sometimes she does not last all 4 hours. she is able to tell them when she has pain and is not tolerating when she points to the areas. Residents Affected - Few During an interview, on 06/20/2024 at 9:24 AM, Staff Q, Restorative Aide, when asked about applying splints and devices to Resident #39, Staff Q replied, we come in at 7:00 AM and at 7:30 AM we start with the braces. The CNAs take the braces off to clean them (referring to the residents). The CNA this morning started to take it off to clean her and I told her not to because it was too soon. After the CNAs take the brace off to clean, we leave it off. It is supposed to be on for 4 hours and sometimes they take it off half hour early. The CNA always tells us when they take it off. This one today is not the regular one. Sometimes she takes it off. She doesn't talk. If she doesn't want it, she takes it off many times. Staff Q further reported they do not document resident removing brace/device. During an interview, on 06/19/2024 at 10:14 AM, the Director of Nursing stated, When I came here in May, there was no Restorative program. I promoted Staff O, and he has done very well. Review of progress notes for the time period 05/20/24 to 06/19/2024 revealed no documentation of Resident # 39 not tolerating devices or having the devices removed. 105120 Page 12 of 32 105120 06/20/2024 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 observations, interviews, and record review, the facility failed to obtain physician's orders for an Indwelling urinary catheter and properly document the care for prevention of urinary tract infections for 1 out of 2 residents reviewed for bladder incontinence with an Indwelling Catheter (Resident #7). The findings included: During an observation conducted on 06/17/2024 at 10:31 AM, Resident #7 was noted to have an Indwelling Catheter in place. A brief interview was conducted with Resident #7 in which he stated that he has had the catheter for a long time. In addition, he acknowledged that the catheter is medically necessary because otherwise he would be in a lot of pain. Record review for Resident #7 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Urinary Tract Infection (UTI), Neuromuscular Dysfunction of Bladder, Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms. Review of the Nursing Progress notes revealed that on 03/25/2024 Resident #7 had a Urologist appointment located outside of the facility. During the appointment, Resident #7 had a procedure for Indwelling Catheter placement. Resident #7 returned to the facility with an indwelling Catheter and orders for clinical monitoring for signs of upper urinary tract deterioration and/or recurrent UTIs. Review of the Physician's Orders showed that Resident #7 had orders dated 12/21/2023 for Tamsulosin HCl Capsule 0.4 mg(milligrams) in the evening for BPH. Methenamine Hippurate (Hiprex) 10mg tablet for UTI; Enhanced Barrier Precaution (EBP) to prevent transmission of multidrug-resistant organism (MDRO) for Obstructive Uropathy with Indwelling medical device dated 05/29/2024 (no orders for an Indwelling Catheter or implementations for catheter care). Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #7 had a Brief Interview for Mental Status (BIMS) of 11, which indicated that he was moderately cognitively impaired. Review of Section H revealed that Resident #7 did not have an Indwelling Catheter and was not taking antibiotics. Review of the Care Plan dated 03/27/2024 documented that Resident #7 had incontinence of Bowel functions and at risk for alteration in skin integrity and infection related to the diagnosis neuromuscular dysfunctions, BPH, history of chronic UTI, and Bacteremia. Interventions were to currently take antibiotics for UTI prophylaxis, monitor urine for odor and output and report abnormalities to physician. Review of the Medication Administration Record (MAR) for March, April, May, and June 2024 revealed that no documentation was noted of Resident #7 having an Indwelling Catheter. In addition, there was no documentation for interventions or maintenance for the Indwelling Catheter. An interview was conducted on 06/17/2024 at 2:48 PM with Staff F, Licensed Practical Nurse (LPN). She stated that a resident with a Indwelling Catheter would have physician's orders in the computer system. In addition, Staff F noted that as needed orders (PRN) for irrigation or if the tubing or catheter bag required changing, would also be included in the physician's orders. She confirmed that 105120 Page 13 of 32 105120 06/20/2024 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 Resident #7 has an Indwelling Catheter in place. Upon review of Resident #7's orders, Staff F acknowledged no orders existed for an Indwelling Catheter nor the interventions for catheter care. During an interview conducted on 06/18/2024 at 11:27 AM, with Staff E, LPN, noted that a resident returning from a doctor's appointment comes back to the facility with paperwork including any new orders. If there are no orders and the resident has an Indwelling Catheter, the nurse receiving the resident would need to contact the doctor's office for the Indwelling Catheter order and then enter it into the computer system. Furthermore, the nurse receiving the resident would do a head-to toe assessment and document the information under the nursing progress notes. During an interview conducted on 06/18/2024 at 11:55 AM, with Staff D, Certified Nursing Assistant (CNA), she noted that Resident #7 has had the Indwelling Catheter for a while. Staff D does not recall how long Resident #7 had the catheter, however, it has been months. An interview was conducted on 06/19/24 at 12:20 PM with the Assistant Director of Nursing (ADON). She stated that Resident #7 went out of the facility in March for an appointment and returned to the facility with an Indwelling Catheter. The ADON acknowledged that the nurse did not enter Resident#7's Indwelling Catheter orders into the computer system. In addition, when she was questioned as to where the nurses were documenting the Indwelling Catheter care and interventions, she .shrugged her shoulders, and did not respond. Review of the facility's policy titled, Appropriate Use of Indwelling Catheters, dated 05/01/23, included the following: It is the policy of this facility to ensure that a resident who is continent of bladder on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility to ensure each resident with urinary incontinence: c. Who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable). 105120 Page 14 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure timeliness of physician visits for 1 of 29 sampled residents (Resident #32). Residents Affected - Few The findings included: Review of the facility's policy titled, Physician Visits and Physician Delegation dated 05/01/2023 included in part the following: 2. The Physician should: b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law. h. At the option of the physician, required visits in SNFs (Skilled Nursing Facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnosis including: Disorganized Schizophrenia, Other Psychotic Disorder Not Due to a Substance or Known Physiological Condition and Major Depressive Disorder. Review of the Minimum Data Set for Resident #32 dated 03/27/2024 revealed in section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. During an interview conducted on 06/20/2024 at 9:45 AM with the Director of Nursing (DON) she revealed she has worked at the facility since beginning of May 2024 When asked how often the primary physician is required to visit the resident, she said upon admission, then every month for the first 90 days then every 60 days, she added they can assign the Nurse Practitioner (NP) or the Physician's Assistant (PA) to see the resident in their place. When asked where the Physicians, Nurse Practitioners (NPs) and Physician Assistants (PAs) document their visits, the DON said in the resident's electronic medical record (EMR). When asked who is responsible for ensuring physician's visits are performed timely, she said it is ultimately the responsibility of the DON. The DON said she runs a report monthly to ensure the resident was seen by the Physician, NP or PA. When asked when Resident #32 was last seen by a physician, she stated it was 12/28/2023 by Staff G (Physician but later discovered to be a Nurse Practitioner). Review of the Physician's Notes for Resident #32 revealed the following: On 01/18/2024, 02/01/2024, 03/06/2024, 04/11/2024, 05/20/2024, 05/22/2024 all Physician's Note was Physician in the past 6 months. 105120 Page 15 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview conducted on 06/20/2024 at 10:57 AM with Staff H's Primary Care Physician (PCP) for Resident #32 who was asked about the frequency of physician visits for residents, Staff H's PCP stated, the goal is to see all patients quarterly. Staff H's PCP reported residents are seen monthly by the NP or PA. Staff H's PCP revealed the facility does not provide a list or schedule of patients to be seen, his practice controls from their end which patients are seen, additionally sometimes residents come and go from the facility, and they may slip through the system and not be seen. 105120 Page 16 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to adequately monitor behaviors for residents receiving psychotropic medications for 5 out of 81 residents receiving psychotropic medications (Resident #32, 34, 96, 5, 116). Residents Affected - Few The findings included: Review of the facility's policy titled; Use of Psychotropic Medication dated 05/01/2023 included in part the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 3. The attending physician, and/or ARNP (Advanced Registered Nurse Practitioner) will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with resident, their families and/or representatives, other professionals and the interdisciplinary team. 1 Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Disorganized Schizophrenia, Other Psychotic Disorder Not Due to a Substance or Known Physiological Condition and Major Depressive Disorder. Review of the Minimum Data Set (MDS) for Resident #32 dated 03/27/2024 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #32 revealed an order dated 01/29/2021 for Behaviors Monitor For The Following: (Hallucination and Pacing) Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings and interventions. Review of the Physician's Orders for Resident #32 revealed an order dated 08/19/2021 for Psychoactive Meds - Monitor for dry mouth, constipation, blurred vision, confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V (Nausea/Vomiting), lethargy, drooling, EPS (Extrapyramidal Symptoms) (Tremors, Disturbed Gait, Increased Agitation, Restlessness, Involuntary Movement of Mouth or Tongue). Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. Review of the Physician's Orders for Resident #32 revealed an order dated 03/20/2024 Risperdal Oral Tablet 1 mg (milligram) give 1 tablet by mouth two times a day for Mood Disorder related to 105120 Page 17 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Disorganized Schizophrenia every shift. Level of Harm - Minimal harm or potential for actual harm Review of the behavior notes and health status notes for Resident #32 for June 2024 revealed no notes related to behaviors or symptoms. Residents Affected - Few Review of the Behavior Monitoring Record for Resident #32 from 06/10/2024 to 06/18/2024 revealed only a check mark each day on each shift (morning, evening and night) for each day. The documentation did not indicate a Y or N as ordered. Review of the CNA (Certified Nursing Assistant) Task for Monitor - Behavior Symptoms for Resident #32 from 06/10/2024 to 06/18/2024 documented the resident had no symptoms. Review of the Care Plan for Resident #32 dated 04/04/2023 with a focus on the resident has episodes of pacing the hallways and talking to the walls. The resident requires cueing and redirecting. The resident is utilizing anti-psychotic medication. The goal was for the resident to have fewer episodes of pacing and talking to the wall by review date. The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet The resident's needs. Caregivers provide opportunity for positive interaction and attention. Stop and talk with him/her as passing by. Monitor for outbursts during pacing episodes and talking to the walls Delusional. Psych consult as needed. Redirect the resident and try to involve him in a group related activity. On 06/17/2024 at 12:09 PM Resident # 32 observed walking through the facility in a pace-like manner. On 06/18/2024 at 7:55 AM Resident # 32 observed walking through the facility in a pace-like manner. During an interview conducted on 06/19/2024 at 2:50 PM with Staff A Licensed Practical Nurse (LPN) who was asked about behavior monitoring how it is documented, she said there is no place to put a Y or N so if the resident has behaviors you mark N and write a behavior note/health status note. Staff A, LPN said it is confusing, but you put a Y if the resident has no behavior and a N if the resident has behaviors. If the resident has behaviors, you put a note in the chart under progress notes to indicate the behavior observed and intervention used like redirecting the resident. When asked about Resident #32 if the resident paces, she acknowledged that the resident paces all of the time. When asked if she documents his pacing, she said no because he does it all of the time, we only document if it is a new or different behavior from what he normally does. During an interview conducted on 06/19/2024 at 3:00 PM with Staff C Certified Nursing Assistant (CNA) who was asked about behavior monitoring, she stated there is a place to document behaviors under Tasks and she would tell the nurse if the resident had behaviors. When asked about Resident #32, she said she would only document behavior that is like hitting or punching or yelling. When asked if the resident paces, she acknowledged he does that all day, every day. When asked if she would document the pacing, for the resident she said no because he does it all of the time and this is his normal behavior. During an interview conducted on 06/19/2024 at 3:10 PM with Staff B Licensed Practical Nurse (LPN) who stated she has worked at the facility for 11 years. When asked about behavior monitoring, she said you document a Y if there are no behaviors for the resident, and a N if the resident is having 105120 Page 18 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behaviors. If the resident has behaviors, then you make a note of what the behavior(s) are that are observed. During an interview conducted on 06/20/2024 at 9:45 AM with the Director of Nursing (DON) who was asked about behavior monitoring for residents receiving psychotropic medications, she stated they are all monitored, and it is documented in the Behavior Monitoring Record (BMR). If the nurse observes behaviors the behavior is documented in a nurse's note and the intervention. 2 Record review for Resident #34 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Parkinsonism and Major Depressive Disorder. Review of the MDS for Resident #34 dated 05/16/2024 revealed in Section C for cognitive pattern a BIMS score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #34 revealed an order dated 01/8/2024 for Venlafaxine HCl Oral Tablet 75 mg give 75 mg by mouth one time a day related to Major Depressive Disorder. Review of the Physician's Orders for Resident #34 revealed an order dated Behaviors - Monitor for the Following: Agitation, Hitting, Increase in Complaints, Biting, Kicking, Spitting, Cussing, Racial Slurs, Elopement, Stealing, Delusions, Hallucinations, Psychosis, Aggression, or Refusing Care. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings and interventions. every shift for antidepressant medication use. Review of the BHR for antidepressant for Resident #34 from 06/10/2024 to 06/18/2024 revealed the following: On 06/10/2024 day and evening shift documented N indicating a behavior was observed. On 06/11/2024 day shift documented N indicating a behavior was observed. On 06/12/2024 day shift documented N indicating a behavior was observed. On 06/13/2024 day and evening shift documented N indicating a behavior was observed. On 06/14/2024 morning and evening shift documented N indicating a behavior was observed. On 06/17/2024 day shift documented N´ indicating a behavior was observed. On 06/18/2024 day shift documented N indicating a behavior was observed. Review of the Nurse Progress Notes and Health Notes for Resident #34 from 06/10/2024 to 06/18/2024 revealed no behaviors documented. Review of the behavior monitoring under CNA Tasks for Resident #34 from 06/10/2024 to 06/18/2024 revealed no behaviors documented. Review of the Care Plan for Resident #34 dated 08/15/2022 with a focus on the resident uses antidepressant medication due to his diagnosis of Depression which increases his risk for alterations in 105120 Page 19 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his mood & behavior and adverse effects of antidepressant medication. The goal was for the resident to be minimized from discomfort or adverse reactions related to antidepressant therapy through the review date. The interventions included: Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Monitor closely for signs and symptoms of EPS (Extrapyramidal symptoms) and notify MD for any new orders with medications. Monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy. 3 Record review for Resident #96 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Depressive Disorder, and Anxiety Disorder. Review of the MDS for Resident #96 dated 05/13/2024 revealed in Section C for cognitive pattern the resident had a Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #96 revealed an order dated 05/06/2024 for Behaviors Monitor for the following: (yelling), picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document: \'Y\' if monitored and none of the above observed. \'N\' if monitored and any of the above was observed, select chart code \'Other\/ See Nurses Notes\' and document findings and interventions every shift for antianxiety medication use. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/2024 for Behaviors Monitor for the following: (yelling), picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document: \'Y\' if monitored and none of the above observed. \'N\' if monitored and any of the above was observed, select chart code \'Other\/ See Nurses Notes\' and document findings and interventions every shift for antidepressant medication use. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/2024 for Psychoactive Meds - Monitor for dry mouth, constipation, blurred vision, confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V (Nausea/Vomiting), lethargy, drooling, EPS (Extrapyramidal Symptoms) (Tremors, Disturbed Gait, Increased Agitation, Restlessness, Involuntary Movement of Mouth or Tongue). Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift for Psychoactive Med Use. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/2024 Buspirone HCl oral tablet 7.5 mg give 1 tablet via PEG-Tube (Percutaneous endoscopic gastrostomy/feeding tube) two times a day related to Anxiety Disorder. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/24 for Mirtazapine Tablet 7.5 mg give 1 tablet via PEG-Tube at bedtime for Depression. Review of the care plan for Resident #96 dated 03/12/24 with a focus on the resident using anti-anxiety medications related to Anxiety disorder. The goals were for the resident to be free from discomfort or adverse reactions related to (r/t) anti-anxiety therapy and will show decreased number episodes of anxiety through the review date. The interventions included: Administer anxiolytic medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift). Monitor for safety. The resident is taking antianxiety meds which are associated with an increased risk of 105120 Page 20 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls with hip and leg fractures. Monitor/document/report PRN any adverse reactions to Anti-Anxiety therapy. Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Review of the care plan for Resident #96 date 03/12/2024 with a focus on the resident uses antidepressant medication r/t (related to) Depression. The goals were for the resident to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The resident will show decreased episodes of s/sx (signs and symptoms) of depression through the review date. The interventions included: Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Monitor/document/report PRN adverse reactions to antidepressant therapy. Review of the BHR for Resident #96 for the month of June 2024 documented for antidepressant medication use on 06/18/24 a N for the day and evening shift indicating behavior and/or symptoms observed. Review of the Health Status Note for Resident #96 on 06/18/24 during the day shift revealed no indication of behaviors. Review of the Health Status Note for Resident #96 dated 06/18/24 at 9:46 PM (evening shift) included the following: Resident attempted many times to remove the Foley catheter which was observed on the bed. MD was called and made aware with new order to remove the Foley catheter and monitor for voiding, if no urine within the hours, reinsert [indwelling catheter] Encourage resident to drink more fluids. Yellow urine was noted in the first diaper. Staff will continue to monitor resident. Hospice nurse was at the facility and informed of the resident's behavior and called hospice doctor who agreed to remove the Foley. All safety measures and comfort in place, close monitoring continue. 4) Record review for Resident #5 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder, Schizophrenia, Dementia, Anxiety Disorder, and Insomnia. Review of the Physician's Orders showed that Resident #5 had orders dated12/06/2023 for Depakote Oral Tablet Delayed Release 250mg for agitation related to Schizophrenia; Risperdal Oral Tablet 1mg for Bipolar Disorder. Monitor for the following Behaviors: (Increased Restlessness) Itching, Picking at Skin, Hitting, Biting, Kicking, Spitting, Cussing, Racial Slurs, Elopement, Stealing, Delusions, Hallucinations, Psychosis, Aggression, Refusing Care. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select Nurses Notes' and document findings and interventions, every shift for antianxiety medication use. Monitor for the following: Dry Mouth, Constipation, Blurred Vision, Confusion, Difficulty Urinating, Hypotension, Dark Urine, Yellow Skin, Lethargy, Drooling, Tremors, Disturbed Gait, Increased Agitation, Restlessness, Involuntary Movement Of Mouth Or Tongue; Document: 'Y' if monitored and none of the above observed, 'N' if monitored and any of the above was observed, and document findings in Nurses/Progress notes, every shift for psychoactive medication use. Review of the Care Plan dated 03/13/2024 documented that Resident #5 uses anti-anxiety medications with the following interventions: Monitor for side effects and effectiveness every shift; Monitor and record occurrence of for target behavior symptoms and document per facility protocol. The resident also uses psychotropic medications due to the diagnosis of Schizophrenia, Bipolar Disorder, and Anxiety. Interventions included: Monitor for side effects and effectiveness every shift; Monitor and 105120 Page 21 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few record occurrence of for target behavior symptoms and document per facility protocol; Monitor/document/report PRN any adverse reactions of psychotropic medications; The resident is on a behavior management program. Review of the behavior monitoring located in the Medication Administration Records (MAR) for antianxiety medication for Resident #5 from 06/01/2024-06/09/2024 revealed the following: 06/01/2024: Day, evening, and night shift documented N (behavior was observed, document the findings and interventions in the Nurses' notes) 06/02/2024: Day, evening, and night shift documented N 06/03/2024: Day shift documented N 06/04/2024: Day shift documented N 06/05/2024: Day shift, evening, and night shift documented N 06/06/2024: Day, evening, and night shift documented Y (no behaviors noted) 06/07/2024: Evening shift documented N 06/08/2024: Day and evening shift documented N 06/09/2024: Evening shift documented N Review of the behavior monitoring located in the MAR for psychoactive medications for Resident #5 from 06/08/2024-06/15/2024 revealed the following: 06/08/2024: Day and evening shift documented N 06/09/2024: Day and evening shift documented N 06/10/2024: Day, evening, and night shift documented Y 06/11/2024: Day, evening, and night shift documented Y 06/12/2024: Day, evening, and night shift documented Y 06/13/2024: Day, evening, and night shift documented Y 06/14/2024: Day, evening, and night shift documented Y 06/15/2024: Day shift documented N Review of the Nursing Progress notes and the monitoring task for the Certified Nursing Assistants (CNAs) revealed no behaviors where documented for Resident #5 between 06/01/2024 - 06/15/2024. 5) Record review for Resident #116 revealed that the resident was admitted to the facility on 105120 Page 22 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] with the following diagnoses: Antisocial Personality Disorder, Adjustment Disorder With Depressed Mood, and Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Psychotic Disorder. Review of the Physician's Orders showed that Resident #116 had orders dated 01/09/24 for Haloperidol Oral Tablet 5mg for Psychosis related to Antisocial Personality Disorder; Sertraline HCl Oral Tablet 100mg for Depression related to Antisocial Personality Disorder. Monitor behavior for the following: (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, document findings and interventions in Nursing/Progress notes every shift for antipsychotic medication use; Monitor the following: dry mouth, hypotension, dark urine, yellow skin, lethargy, drooling, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue, document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, document findings in nurses' notes and progress note every shift for psychoactive medication use. Review of the Care Plan dated 04/12/24 documented that Resident #116 uses psychotropic medications with the following interventions: Monitor for side effects and effectiveness every shift; Monitor and record occurrence of for target behavior symptoms and document per facility protocol. Monitor/document/report PRN any adverse reactions of psychotropic medications. Review of the behavior monitoring located in the MAR for antipsychotic medications for Resident #116 from 06/11/2024-06/18/2024 revealed the following: 06/11/2024: Day and evening shift documented N 06/12/2024: Day, evening, and night shift documented Y 06/13/2024: Day, evening, and night shift documented Y 06/14/2024: Day, evening, and night shift documented Y 06/15/2024: Day, evening, and night shift documented Y 06/16/2024: Day, evening, and night shift documented Y 06/17/2024: Day, evening, and night shift documented Y 06/18/2024: Day and evening shift documented N Review of the Nursing Progress notes and the monitoring task for the Certified Nursing Assistants (CNAs) revealed no behaviors where documented for Resident #116 between 06/11/2024 - 06/18/2024. An interview was conducted on 06/20/2024 at 3:15 PM with Staff J, Registered Nurse (RN). She stated that nurses monitor behaviors for residents on psychotropic medications. Staff J also stated the orders for monitoring behaviors are for all shifts and are documented in the MAR and in the progress notes if there's a behavioral concern. She acknowledged that the questions for behavior monitoring are confusing, and nurses can easily enter the wrong information. 105120 Page 23 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0757 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 06/20/2024 at 3:50 PM with Staff K, Certified Nursing Assistant (CNA). If observed a resident with behaviors, Staff K stated that she reports it to the floor nurse or the unit supervisor. She acknowledged that she would answer the questions under the Behavior task, but the documentation is done by the nurse. Residents Affected - Few 105120 Page 24 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

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 observations record review and interview; the facility failed to secure medications at bedside for 1 of 29 sampled residents (Resident #34). As evidenced by medication (eye drops) observed on the resident's nightstand. The findings included: Review of the facility's policy titled, Medication Storage dated 05/01/2023 included in part the following: 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. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Record review for Resident #34 revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including: Parkinsonism and Major Depressive Disorder. Review of the Minimum Data Set for Resident #34 dated 05/16/2024 documented a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the physician's orders for Resident #34 revealed an order dated 11/23/2023 for Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop in both eyes two times a day for Dry eyes On 06/17/2024 at 3:15 PM an observation was made of Resident #34 sitting on side of his bed, on his nightstand in plain sight was Advanced Relief Moisture eye drops with an unreadable written date on the box of XX/15/2024 and another date of 06/15/2024 just below handwritten D/C (discontinue) The active ingredients were listed as: Dextan70 0.1%, Polyethylene glycol 400 1%, Povidone 1%, and Tetrahydrozoline HCL 0.05%. (Photographic Evidence Obtained). On 06/18/2024 at 8:20 AM a second observation was made of Resident #34 lying in bed and on his nightstand in plain sight was Advanced Relief Moisture eye drops with an unreadable written date on the box of XX/15/2024 and another date of 06/15/2024 just below handwritten D/C. During an interview conducted on 06/17/2024 at 3:15 PM with Resident #34 who was asked about the eye drops on the nightstand, he said the staff put them in his eyes twice a day for him. During an interview conducted on 06/18/2024 at 1:49 PM with Staff A Licensed Practical Nurse (LPN) who was asked if Resident #34 receives eye drops, she said yes, she gave them to the resident this 105120 Page 25 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning with his other medications. When asked to see the eye drops, the LPN opened her med cart and pulled out a box with eye drops dated 06/14/2024. There was no room number or resident name on the box to identify which resident the drops were for. When asked how she knows the eye drops are for Resident #34, the LPN stated: he is the only one in my area that has over the counter eye drops, all other residents with eye drops are prescription and they are sent from the pharmacy with the resident name on them. The eye drops the LPN had pulled out of her med cart were Sterile Eye Drops Original containing 1 active ingredient: Tetrahydrozoline HCL 0.05% (Eye Redness Reliever). The LPN accompanied surveyor to the bedside of Resident #34 and acknowledged the eye drops on top of the nightstand. The LPN revealed she did not notice the eye drops at the bedside because the resident had so many items on top of his nightstand. The LPN was asked what the order for the eye drops stated for Resident #34, the LPN acknowledged the order was for Artificial Tears. When asked if either of the eye drops in the cart for the resident or the eye drops at the resident's bedside were artificial tears, she stated I think so. The LPN removed the eyedrops at the bedside immediately. During an interview conducted on 06/18/2024 at 1:55 PM with the Consultant Pharmacist who was asked if the Sterile Eye drops containing Tetrahydrozoline HCL 0.05% or the Advanced Relief Moisture eye drops containing: Dextan70 0.1%, Polyethylene glycol 400 1%, Povidone 1%, and Tetrahydrozoline HCL 0.05% were a substitute for the ordered Artificial Tears for Resident #34, he said no, but he will take care of it. 105120 Page 26 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide food prepared in a pureed form designed to meet the needs of 2 sampled residents (Resident's #1, and #43) out of 12 facility residents with physician ordered pureed diet. The findings included: 1) During the observation of the breakfast meal in the Main Kitchen on 06/18/2024 at 7:30 AM it was noted that the pan of pureed eggs located in the steam table appeared to be lumpy and were not smooth in consistency. The surveyor requested the eggs to be taste tested by the facility's Registered Dietitian at the time of the observation and it was noted that the dietitian revealed the eggs were gritty in consistency and large pieces of eggs were not properly blundered into a smooth consistency. The Dietitian reported the eggs should not be served to residents with a physician ordered pureed diet. It was requested that the eggs not be served until proper pureed consistency was obtained. Interview with the breakfast cook (Staff I) at the time of the observation it was also noted that she does not taste test the consistency of pureed foods and had not been in-services on the preparation of pureed foods. 2) During the observation of the lunch meal in the Main Kitchen on 06/18/2024 at 11:30 AM, it was noted that the pureed herb crusted fish located on the steam table appeared to have particles of food within the fish mixture. At the request of the surveyor the purred fish was taste tested by the facility's Registered Dietitian. The testing confirmed that the pureed fish mixture was not smooth and small pieces of fish could be detected. The pureed fish was also tested by the surveyor and confirmed that the purred mixture was not smooth and pudding like. The surveyor requested that the fish not be served until pureed to the proper smooth consistency required for pureed foods. 3) Review of the facility Diet Census for 06/18/2024 noted that there were currently 14 residents with physician ordered pureed diets. Further review noted that the 14 residents included sampled Residents #1, and #43. 4) Review of the clinical records of Resident's #1 revealed Resident #1 was admitted to the facility on [DATE]. Clinical diagnoses include Convulsions and Dysphagia. Current Physician Order dated 7/17/2022 indicated: No Added Salt/Pureed texture. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section C for cognitive pattern documented a Brief Interview For Mental Status (BIMS) score of 2 out of 15 suggesting severe cognitive impairment Section K for Swallowing/Nutritional Status indicated the resident is on a mechanical Alt Pureed Diet. Review of Resident #43's records documented the resident was admitted to the facility on [DATE]. Clinical diagnoses include Dysphagia. review of current Physician Orders dated 8/30/2023 showed an order for No Added Salt, Pureed Texture. Review conducted on 06/19/2024 of the facility's physician approved Diet Manual for Pureed Diet Dysphagia Level 1 noted the following: The Pureed consistency is planned according to the Regular consistency, but the mixture is modified to smooth, pudding-like consistency texture for all food 105120 Page 27 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0805 Level of Harm - Minimal harm or potential for actual harm items. The consistency follows the guidelines as set forth by the National Dysphagia Task Force. This consistency is designed for people who have moderate to severe Dysphagia. Pureed recipes are needed for each item to achieve a pudding-like, smooth, lump free, pureed consistency. Residents Affected - Few 105120 Page 28 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Residents Affected - Some The findings included. 1) During the initial kitchen/food service observation tour conducted on 06/17/2024 at 9:00 AM accompanied with the facility's Foods Service Director (FSD) and Registered Dietitian (RD), the following were noted: a) There was a large leak in the ceiling area located in front of the steam table and milk cooler. Further noted that there was an accumulation of water on the floor beneath the leak area. It was revealed by the Registered Dietitian that the leak occurred a few days ago. It was discussed that there was the potential for the contamination of food, equipment, and staff from the dripping of contaminated water. It was requested that the floor area underneath the leak be repaired immediately and to stop any food, staff and equipment from going under the leak area. b) Observation noted a ceiling mounted air-conditioning vent located over the steam table serving area had an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for food contamination from the contaminated drippings. c) Observation noted a ceiling mounted air-conditioning vent located over the commercial milk storage refrigerator. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for the milk to become contaminated from the condensation drippings. d) Observation noted a ceiling mounted air-conditioning vent located over the 3-compartment sink area. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for clean preparation equipment to become contaminated from the condensation drippings. e) Observation noted a ceiling mounted air-conditioning vent located over the juice dispenser area. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for juice's to become contamination from the condensation drippings. f) Observation noted a ceiling mounted air-conditioning vent located over the center of the dish machine room. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for clean dishes and staff to become contaminated from the condensation drippings. g) At the request of the surveyor a chemical test was conducted by the FSD of the low-temperature commercial dish machine. The chemical test noted that the Chlorine test strip indicated no presence of sanitizing chemical present in the final rinse and did not meet the regulatory requirement of a 50 PPM. The washing of dishes was requested to be stopped until the regulatory requirement was met. 105120 Page 29 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some h) At the request of the surveyor a chemical test of the 3-compartment sink was conducted by the FSD. The chemical test noted that the Quaternary chemical exceeded the minimum requirement (150 PPM) and was determined to be a toxic level of over 300 PPM. The washing of food preparation equipment was requested to be stopped until the regulatory chemical level was met. i) During the observational tour it was noted that a large pan of raw chicken (approximately 10 pounds) was located in the cooks preparation sink. Further observation noted that only a small stream of water was flowing over the raw chicken. It was also noted that small stream of water flowing onto the chicken was warm to the touch. At the request of the surveyor the temperature of the flowing water was tested with the facility's calibrated bayonet thermometer; the temperature of the water was recorded at 85 degrees F. The surveyor informed the FSD that the thawing process did not meet regulatory requirement. The FSD was informed that the temperature of the flowing water must be 70 degrees F or below and must be at a high force to remove particle of chicken. The surveyor requested that the chicken be discarded. (J) Observation of the reach-in refrigerator there was a large tear noted in the door gasket and 5 of the food storage shelves located within the unit were rusted. (K) The surveyor requested the cleaning cloth bucket #1 be tested for sanitizing chemical presence. The test conducted by the facility Registered Dietitian noted that there was no sanitizing chemical (Quaternary) present in the bucket to meet regulatory requirement. (L) Numerous cooking equipment (pots & pans - 5) were noted to be covered in a thick black carbon matter. The surveyor discussed with the facility's Registered Dietitian that the carbon could result in food contamination during preparation and that the equipment be replaced as soon as possible. 2) During a second observation of the main kitchen on 06/18/2024 at 6:45 AM accompanied with the FSD and Registered Dietitian, the following were noted: a) The interior of the main exhaust system located above the major cooking equipment was noted to be rust laden throughout the entire surface of the unit. b) The plate warming lowerator was noted to be broken and too many resident entree plates were being stored within the unit. c) Numerous resident entree plates located within the plate lowerator were noted to be broken and chipped (15). The surveyor requested that the plates be observed prior to serving and to discard the broken/chipped plates. d) The maintenance director was noted to be located within the food production and serving area. Further observation noted that the director failed to don a beard/mustache guard. e) The temperatures of foods located on the steam table were taken with the facility's calibrated bayonet thermometer by the facility's Registered Dietitian. The temperature testing noted that hot foods were not being held at the minimum regulatory temperature of 135 degrees or greater. The temperatures were recorded as follows: * Pureed Scrambled Eggs (20 servings) = 110 degrees F 105120 Page 30 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0812 * Pureed French Toast (20 servings) = 112 degrees F Level of Harm - Minimal harm or potential for actual harm 3) During a third kitchen observation conducted on 06/19/2024 at 11:30 AM it was noted that a diet aide was wrapping silverware in an unsanitary manor. Specifically, the silverware was located in a large open dish reach. Staff were noted to be handling the silverware by the eating stem and putting it into silverware bags. The facility's Registered Dietitian was requested to observe the handling of the silverware and confirm the findings. Further stated that the silverware not being washed properly in the required 3-step process to ensure proper handling. Residents Affected - Some 105120 Page 31 of 32 105120 06/20/2024 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview it was determined that the facility failed to dispose of garbage and refuse properly. Residents Affected - Some The findings included: Observation of the garbage/dumpster area located outside at the rear of the facility on 06/17/2024 at 9 :15 AM and accompanied with the facility's Registered Dietitian, the following were noted: (a) The dumpster was noted to be overflowing and that resulted in the lids (2) being unable to be closed. Broken bags of garbage/trash were noted to be within the open dumpster cavity and falling down onto the ground area in front of the dumpster. (b) Due to the overflowing dumpster addition bags (30) of trash /garbage and nursing waste was noted to be stored on the ground area approximately 10 feet from the dumpster. Numerous bags were noted to be ripped open resulting in trash, garbage, and soiled PPE supplies (gloves, gowns, etc.) to be strewn around the ground area in front of the bags. c) Interview with the Administrator following the 06/17/24 tour noted to state that there was recent flooding in the area resulting in delay of routine trash pick-up. It was discussed that the ground area and bags should be monitored daily for torn bags that contain garbage, trash and PPE be cleaned daily. * Photographic evidence obtained for examples (a) and (b). 105120 Page 32 of 32