Health inspection·July 13, 2023

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 review, the facility failed to implement care plan interventions related to bleeding precautions for two residents (#89, #93) and failed to develop and implement a comprehensive care plan related to a nephrostomy tube for one resident (#89) out of 30 residents sampled. This had the potential to affect the 150 residents residing in the facility receiving care at the time of this survey. The Findings Included: 1. During observation on 07/10/23 at 09:37 AM, Resident #89 was in bed awake, with a right side quarter side rail pad on the floor, and a left side quarter side rail pad was attached to the bed rail on the upper inside of the bed. The urinary tubing leading from the resident's left side to the drainage bag was attached to the lower bed rail. Resident #89 stated, he is doing great today. On 07/11/23 at 08:25 AM, Resident #89 was observed in bed eating breakfast, there was no distress noted, bilateral quarter rail pads were in place and the urinary tubing was present. On 07/12/23 at 08:47 AM, Resident #89 was observed in a high-back wheelchair in the hallway, the resident stated, he just went to therapy, and he even walked a little bit yesterday. The urinary drainage bag was in a privacy bag. Record review of Resident # 89's Care Plan with a Reference Date of 07/12/23 revealed: Resident is at risk for abnormal bleeding or hemorrhage related to: Anticoagulant use/Eliquis as ordered. Interventions: Monitor for signs and symptoms (S/S) of bleeding every shift (bleeding gums or nose, unusual bruising, dark/tarry stools, pink/discolored urine). Maintain on bleeding precautions every shift. Document if abnormalities noted, notify provider at once for appropriate interventions needed. Record review of Resident # 89's Care Plan Reference Date 07/12/23 revealed: 05-12-23 Left nephrostomy tube (FR8) inserted on 05-12-23. Diagnosis Left urinary tract obstruction proximal left ureter calculus. Interventions included: Assess urine output every shift. If abnormalities noted- scanty or no output: Record the amount, type, color, odor. Observe for leakage. Notify provider at once if abnormal s/s noted for appropriate interventions. Follow up Nephrology consultation as ordered. Report at once to provider signs and symptoms of Urinary Tract Infection (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine) for appropriate intervention. Educate and encourage resident to report pain and/or persistent flank pain on shift. Notify provider at once if suspects blockage. Left Nephrostomy site care: Monitor and document urinary output Page 1 of 13 105252 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from Urostomy bag every shift. Empty bag at the end of each shift. Keep the drainage bag low to avoid urine from backing up. Keep drainage tube secured to avoid dislodgement. Review of the medical records for Resident #89 revealed, the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Clinical diagnoses included but were not limited to: Malignant neoplasm of prostate (History of), Atrial Fibrillation and other seizures. Review of the Physician's Orders Sheet for June-July 2023 revealed, Resident #89 had orders that included but were not limited to: Nephrology consult: Left nephrostomy tube inserted on 05/12/23. Dx. Left urinary tract obstruction proximal left ureter calculus. 07/12/23-Bleeding Precautions. Monitor for signs of bleeding every shift and report to provider. Special Instructions: Resident on Eliquis. Medications included: Eliquis (apixaban) tablet; 5 Milligram (mg)-Give one tablet daily for Atrial fibrillation. Record review of Resident #89 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 12, on a 0-15 scale indicating the resident is cognitively moderately impaired. Section G for Functional Status documented Total Dependence for transfer and toileting, Extensive assistance for bed mobility with one person assistance, and Eating-independent. Section H for Bowel and Bladder documented, Resident has an Indwelling catheter (including suprapubic catheter and nephrostomy tube), always incontinent of bowel. Section J for Health Conditions documented resident received scheduled pain medications in the last 5 days, shortness of breath when sitting at rest and lying flat. Section K for Nutritional Status documented, no unknown weight loss/gain. Section M for Skin Conditions documented no skin issues. 2. During observation on 07/10/23 at 09:16 AM Resident #93 in wheelchair in room, stated today is a great day. On 07/11/23 at 08:21 AM, Resident #93 was in the wheel chair in the room eating breakfast, the oxygen equipment dated 7/10/23, stated, today is a good day. On 07/12/23 at 10:00AM, Resident #93 was in the wheel chair in the hallway, and stated everything is great today. Record review of Resident # 93's Care Plan with a Reference Date 06/25/23 revealed: Resident is at risk for abnormal bleeding or hemorrhage related to: Anticoagulant use/Eliquis: Paroxysmal Atrial Fibrillation. Interventions: Obtain labs as ordered, notify provider at once of abnormal result. Monitor for s/s of bleeding every shift (bleeding gums or nose, unusual bruising, dark/tarry stools, pink/discolored urine). Maintain bleeding precautions every shift. Document if abnormalities noted, Notify provider at once for appropriate interventions. Administer anticoagulant medication as ordered. Review of the medical records for Resident #93 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Paroxysmal atrial fibrillation. Review of the Physician's Orders Sheet for June-July 2023 revealed, Resident #93 had orders that included but were not limited to: 7/12/23-Bleeding Precautions. Monitor for signs of bleeding every shift and report to provider. Special Instructions: Resident on Eliquis Every Shift Morning, Evening, 105252 Page 2 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Night. Medications Included: Eliquis (apixaban) tablet; 5 mg-Give one tablet twice a day for Atrial Fibrillation. Record review of Resident #93 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 15, on a 0-15 scale indicating the resident is cognitively intact. Section G for Functional Status documented Total Dependence for Activities of Daily Living. Section H for Bowel and Bladder documented Resident is always incontinent of bowel and bladder. Section M for Skin Conditions documented no skin issues. Section N for Medications documented resident received antidepressant, anticoagulant and insulin in the last 7 days. Interview on 07/12/23 08:11 AM with Registered Nurse (Staff A) showed surveyor order for resident's Eliquis, stated she will check the treatment Electronic Medication administration Record (EMAR) for monitoring parameters for Eliquis, Staff A checked treatment orders with the surveyor, there was no order for monitoring the resident for bleeding or bruising. Staff A stated, the residents on anticoagulants usually have orders for monitoring for bleeding and bruising. Staff A stated, this resident is stable and he is able to verbalize his needs, when the Nursing Aides provide care to the resident, they would report any issues with the resident to the nurse. Interview on 07/12/23 at 08:18 AM with the Registered Nurse Unit Manager for the East wing (Staff B) stated, she will look into the resident's medical record related to bleeding precautions monitoring and discuss with the resident's physician and let the surveyor know. Interview on 07/12/23 at 02:47 PM with the Director of Nursing (DON), when asked about residents' #89 and #93's care plan intervention for anticoagulant therapy proceeded to look up the resident's medical records, the DON stated, the interventions states to monitor the resident for signs and symptoms of bleeding, when asked how are the direct care staff monitoring the resident, the DON proceeded to check the resident's orders, the DON stated there are no orders in place and there should be an order for monitoring the residents for bleeding precautions. Additionally, the DON stated an order was created today on 7/12/2023 on the medication flow sheet and EMAR to monitor bleeding precautions for the residents. The DON stated, there should have been an order in place for monitoring the residents (Bleeding Precautions). The DON stated I will be doing audits for residents on anticoagulants, identify that there is documentation that the residents are being monitored for signs and symptoms of bleeding and being signed off by the nurse. Interview on 07/12/23 at 03:00 PM, the DON when asked about what type of catheter Resident #89 currently has, proceeded to check the resident's medical records, and stated, this resident uses a condom catheter and has a left nephrostomy tubing with a drainage bag that was placed on 5/12/23 during the most recent hospital admission. After reviewing Resident #89's care plans, the DON stated this resident does not currently have a care plan for the nephrostomy tube, the most recent Minimum Data Set (MDS) dated [DATE] documented the resident has an indwelling Catheter (the includes a nephrostomy). The resident does not currently have a care plan for the nephrostomy tube. The Minimum Data Set (MDS) team completes the resident's MDS' and the care plan, according to the medical records there is no care plan currently in place for the resident's nephrostomy. The DON spoke with the MDS team, and reported a care plan will be implemented for the resident's nephrostomy tube, an audit will be conducted for all residents with indwelling catheters to make sure they are coded correctly, and the care plans are in place. Review of the facility's policy and procedure titled, Interdisciplinary Care Plan revision date 105252 Page 3 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0656 04/08/2022 states: Planning of Care: Care plans are resident centered with measurable goals. There are basic steps to progress care planning: Level of Harm - Minimal harm or potential for actual harm Assessment-Individual and comprehensive (MDS) Residents Affected - Few Planning-CAA (care area assessment) Analysis and Recommendation Identification of Problem/Need-with Team Measurable goals and meaningful approaches Implementation of the Plan Evaluation of the effects of the approaches on the goals Nursing Assistant's input is critical to the care planning process. Goals can take different forms-improvement, maintenance, preventative, palliative and coping and change between quarters. Approaches need to be clear and responsibility in application assigned. Any member of the care team can and should update the plan of care when new information is appropriate and different from what exists at the time. 105252 Page 4 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

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. Based on observation, record review and interview, the facility failed to provide adequate and appropriate health care, related to occupational therapy services for two (Resident #65 and 88) out of two residents reviewed. There were no hand rolls observed in the residents hands. The findings included: 1. Resident #65 face sheet review showed the initial admission date of 08/13/20, with diagnoses including but not limited to, Hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side Primary. Observation of Resident #65 on 07/10/23 at 09:29 AM revealed, the resident was observed sitting in his wheelchair with the left hand contracted, and no splints were observed. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 05/29/23 revealed, Sections C - Cognitive Patterns - 03 out of 15, indicating severe cognitive impairment, Section E - Behavior - Behavior not exhibited, Section F - Preferences for Customary Routines - N/A, G Functional Status (including bed mobility, transfer and ROM status) -Total dependence/one, I - Active Diagnoses - Anemia, Hypertension, Diabetes Mellitus (DM), Hyperlipidemia, Seizure Disorder or Epilepsy, Malnutrition, Depression, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Other specified diabetes mellitus with diabetic neuropathy, unspecified, Nutritional deficiency, unspecified, Other muscle spasm, Constipation, unspecified, Sleep apnea, unspecified, Pain, unspecified, Essential (primary) hypertension. Section J - Health Conditions - Pain and Falls - Yes, received pain medication, and Section O - Special Treatment/Proc/Prog - OT (O0400B)(Occupational Therapy) None, PT (Physical Therapy) (O0400C) - None, and restorative nursing program (O0500). Record review of the residents Physician's orders revealed an order dated 07/07/23 for a Wash cloth roll to the left hand to be worn at all times. Remove for skin checks and for hygiene and to change roll. Special Instructions: At all times Every Shift Morning, Evening, Night. Review of resident #65's Care Plans Dated 07/11/23 revealed: Problem: Decreased in ADL (Activities of Daily Living) functions: Decreased in functional mobility Resident requires total assistance x1 person with bed mobility, dressing, personal hygiene, toilet use and bathing activity. [Resident is able to eat independently with meal tray set up=Revised] [Resident needs supervision for safety with meal tray set up=02-26-22 Revised] Resident needs total assistance x1 person when eating at this time. =revised. Resident is able to eat independently with set up. Resident fluctuates with eating assistance. Resident prefers to be feed almost all the time. He tends to eat longer with a lot of encouragement when supervised but is able to establish normal pace when provided assistance with meals as requested. He requires total assistance x2 person with transfer for safety using mechanical lifter. He is non ambulatory. He needs total assistance x1 person to move on and off the unit while in wheelchair. Resident is at risk for fluctuation in status related to multiple medical conditions. DX: DM DX: HTN History of CVA (Cerebrovascular Accident) with left hemiparesis. Goal: Resident will maintain comfort and hygiene on a daily basis and will receive the total care needed with dignity thru next review date. Resident will not show s/s (signs and symptoms) of further decline in ADL functions and related complications thru next review date.e.g., ROM 105252 Page 5 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Range of Motion) and mobility schedules including types of interventions, positioning interventions, assistance devices, type of splinting [e.g., splint, hand roll, arm trough], pain, care of contracture). During an interview with the Physical Therapist Rehab Manager on 07/13/23 at 09:04 AM, it was stated, I know he has it; I think. A hand roll towel is supposed to be there every day as tolerated. I know that he does not have it because sometimes the towel moves. Interview with Staff F, a Registered Nurse on 07/13/23 at 09:53 AM it was reported, the order is that he has to have the towel roll every day, but I do not know why he did not have it. Sometimes the resident is the one who takes it off. Interview with Staff G, a Certified Nursing Assistant(CNA) on 07/13/23 at 09:53 AM, it was reported, she has been working in the facility for 20 years, Her schedule is five days a week from 7:00 AM to 3:30 PM. I am supposed to put the towel every day, I do not know what happened, that he did not have it when you saw him. 2. Resident #88 face sheet review showed the initial admission date of 10/27/22, with diagnoses including but not limited too: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Peripheral vascular disease, unspecified, Type 2 diabetes mellitus with other specified complication, and Contracture, right hand. Observation of Resident #88 on 07/10/23 at 09:06 AM revealed, the resident was lying in bed with a right hand contracted. There was no roll observed in the residents hand. Second observation on 07/13/23 09:40 AM revealed, the resident lying in bed with a towel roll in his hand, the resident stated; they just put it on. Record review of the residents Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 05/15/23 Sections C - Cognitive Patterns - Left blank, Section E - Behavior - Behavior not exhibited, Section F - Preferences for Customary Routines - None, G - Functional Status (including bed mobility, transfer and ROM status) -Total dependence/Two+, Section I - Active Diagnoses - Heart Failure, Hypertension, Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD), Diabetes Mellitus (DM), Hyperlipidemia, Non-Alzheimer's Dementia, Hemiplegia or Hemiparesis, Malnutrition, Depression, Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease, Disorder of the skin and subcutaneous tissue, unspecified, Partial traumatic amputation of one left lesser toe, subsequent encounter, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant, Paroxysmal atrial fibrillation, Unspecified injury of flexor muscle, fascia and tendon of other finger at wrist and hand level, subsequent encounter, Contracture, right hand, Gastro-esophageal reflux disease without esophagitis, Constipation, unspecified, Pressure-induced deep tissue damage of right heel, Other muscle spasm. Section J - Health Conditions - Pain and Falls - None, and O - Special Treatment/Proc/Prog - OT (O0400B) - None, PT (O0400C) - None, and restorative nursing program (O0500) - Range of motion (passive). Record review of the Physician's orders revealed an order dated 03/07/23 for a Roll to Rt hand at all times to prevent skin breakdown in palm and thumb region. Special Instructions: Clean hand and provide roll to hand. Every Shift Morning, Evening, Night. Record review of the residents Care Plans Dated 05/01/23 revealed: 105252 Page 6 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Problem: [Use of bedside rails as enabler Use of bedside rails as enabler/support: Resident presents impaired balance & gait. Use of bed side rails will assist resident with bed mobility/enable safe transfers to and out of bed/improve balance while sitting at the edge of the bed.] DISCONTINUE PLAN OF CARE INCLUDING GOALS AND APPROACHES. Goal: Resident will be able to facilitate movement and benefit with the use of bedrails as enablers and reduce related complications e.g., minimize risks of pressure ulcer development and/or bodily injury thru next review date. Resident bed mobility will not be impeded and will not prevent resident from physically moving freely and will not be physically confine and restricted thru next review date. Problem: Resident admitted for rehabilitation. Resident has hx/o (history of) homelessness. LTC (Long term care) is likely the plan of choice. Resident admitted under guardianship. Goal: Will continue receiving the level of care and medical attention from the SNF. Will communicate needs and concerns. Will accept daily care and treatment. Will accept redirection from staff as needed. Problem: ADL's functional Status/Rehabilitation potential. Decreased in ADL functions: Decreased in functional mobility, Resident needs total assistance x1 person with bed mobility=revised. Resident needs extensive assistance x1 person with bed mobility. He needs extensive assist x1 person with dressing, toileting, bathing, and personal hygiene=revised. Goal: Resident will maintain comfort and hygiene on a daily basis and will receive the total care needed with dignity thru next review date. Approach: PT evaluation and treatment as ordered. OT evaluation and treatment as ordered. During an interview with the Physical Therapist Rehab Manager on 07/13/23 at 08:57 AM, it was stated We just put a towel roll when he tolerates it, but he does not like to use it. The towel roll is supposed to be put daily but I do not know exactly at what time. The Resident tends to remove them without us knowing it. Usually, the CNA is supposed to put the towel roll every day after the morning care. The last screening/evaluation was conducted on 05/26/23, the outcome was that he did not desire to participate in any restorative services. Interview with Staff D, a Registered Nurse on 07/13/23 at 09:42 AM it was reported, the resident has the order for a towel roll for every shift, we have to check to make sure that he has it on. We check on the resident every two hours and we have to make sure that he is using the towel roll. Sometimes the resident removes the towel because he does not like it. Interview with Staff E, a CNA, on 07/13/23 at 09:47 AM it was stated, I am in charge of taking care of the resident, I am supposed to put the towel roll every day and check on him every two hours. The Resident sometimes drops the towel, thus why he does not have it. Record review of the Policy and Procedure titled, Splinting Program, Policy No. 2250, revisied 03/23/2022 revealed: I. Purpose Devices such as hand rolls, hand, wrist, ankle or knee splints or upper extremity sling may be used to immobilize a joint to: 1. Prevent a contracture. 2. Reduce a contracture. 3. Provide extremity support to improve function. 105252 Page 7 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0688 III. Procedure Level of Harm - Minimal harm or potential for actual harm 1. Resident deficit/need/problem is identified by Nurse, Occupational Therapist or Physical Therapist assessment. Residents Affected - Few 2. If hand roll is indicated, the Medical Director (MD)/Advance Practice Registered Nurse (APRN)/Therapist may write order for them. 3. Occupational Therapist or Physical Therapist writes a specific order stating type of splint to be used, area to which splint is applied, duration of application time, duration of removal time, and other special instructions. 4. Occupational Therapist, Physical Therapist provides necessary education to guarantee appropriate and usage of splint.Facility failed to provide adequate health care related to occupational therapy for resident # 88 and # 65 105252 Page 8 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe environment related to bed side rail pads to prevent accidents for one Resident (#89) out of one sampled resident. This had the potential to affect the 150 residents receiving care in the facility at the time of the survey. The Findings Included: During observation on 07/10/23 at 09:37 AM, Resident #89 was in bed awake, a right side quarter side rail pad was on the floor, the left side quarter side rail pad was attached to the bed rail on the upper inside of the bed, the bed was not in the lowest position. Resident #89 stated, he is doing great today. On 07/11/23 at 08:25 AM, Resident #89 was observed in the bed eating breakfast, no distress was noted, bilateral quarter rail pads were in place, the bed was not in the lowest position. On 07/12/23 at 08:47 AM, Resident #89 was observed in a high-back wheelchair in the hallway, and stated he just went to therapy, and he even walked a little bit yesterday. Review of the medical records for Resident #89 revealed, the resident was admitted to the facility on [DATE], and readmitted on [DATE]. Clinical diagnoses included but were not limited to: Atrial Fibrillation and other seizures. Review of the Physician's Orders Sheet for June-July 2023 revealed, Resident #89 had orders that included but were not limited to: 5/18/23-Bilateral bed Side Rail Padded for Seizure Precautions Special Instructions: Use & monitoring of Side Rails For seizure/convulsion activities. Every Shift Morning, Evening, Night. Medications included: 5/17/23-Keppra (levetiracetam) tablet; 1,000 Milligram (mg) give one tablet twice a day for seizures. Record review of Resident #89 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 12, on a 0-15 scale indicating the resident is cognitively moderately impaired. Section G for Functional Status documented Total Dependence for transfer and toileting, Extensive assistance for bed mobility with one person assistance, and Eating-independent. Section H for Bowel and Bladder documented Resident has an Indwelling catheter (including suprapubic catheter and nephrostomy tube), always incontinent of bowel. Section J for Health Conditions documented resident received scheduled pain medications in the last 5 days, shortness of breath when sitting at rest and lying flat. Section K for Nutritional Status documented no unknown weight loss/gain. Section M for Skin Conditions documented no skin issues. Review of Resident #89's Care Plans with a Reference Date 06/26/23 revealed: Use of bedside rails with pads as safety device related to Seizure Disorder. Interventions Included: Monitor for any seizure activities on shift. Notify provider at once for appropriate intervention necessary. Maintain on seizure precaution at all times. Keep bed in lowest position with padded side rails in place at all times. Educate safety precautions and allow resident to demonstrate use of side rails: resident's ability to be physically free from confinement. Assess medical condition/cognitive and behavioral status that presents potential risk for entrapment. Apply two side rails up 1/2 top and 1/2 bottom with 105252 Page 9 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0689 pads for safety. Level of Harm - Minimal harm or potential for actual harm Review of the nursing progress note dated 05/07/2023 time stamped 09:00 documented, resident left the facility via 911, family unable to contact. Physician (MD) aware. Residents Affected - Few On 05/07/2023 timestamped 08:45 Resident noted continuously jerking movements unable to speak or follow commands. Vital Sings: B/P 185/116, P-124, R- 32, T-97.7, O2 Sat-92. MD was called and gave order to Call 911. Review of the Physician's notes on 05/19/2023 time stamped 00:06 documented: Patient admitted to hospital from [DATE] to 5/17/23. Chief complaints: new onset seizure. History of Present illness: [AGE] year-old . with essential hypertension, diabetes, prostate cancer with bone Mets sent from the nursing home after having a seizure. In the emergency department (ED) patient was unable to complete thoughts or sentences. In the ED he was febrile. He was found to have acute kidney injury. admitted under Medicine for further evaluation and treatment. Found to have the left hydroureter with hydro nephrosis. Blood culture positive for Proteus mirabilis. Started on IV antibiotics. Subsequent cultures negative. Nephrostomy done in the left on 5/12/23. Patient also with atrial flutter. Being followed by cardiologist. Started on metoprolol, amiodarone apixaban. Interdisciplinary team (ID) recommended Bactrim to complete 14 days of Antibiotics. Patient also with Hypokalemia and low magnesium level. Interview on 07/12/23 at 08:15 AM with Registered Nurse, (Staff A) it was stated, the resident started with seizure problems about two months ago, he is stable now, he goes to therapy but he likes to be in bed, the quarter rail pads is for protection if he has a seizure, he went out to the hospital 911 for a seizure, the rail pads should be on at all times when the resident is in bed. Interview on 07/12/23 at 08:36 AM with the Registered Nurse Unit Manager (Staff B) it was stated, we do have an order for the resident to have the rail pads on the bed, so we will have to educate the resident and staff about why the seizure pads are in place and to make sure that the rails pads are always on when the resident is bed. Interview on 07/12/23 at 08:51 AM with Certified Nursing Assistant (CNA)(Staff C) stated, I have been working here for two years, I am assigned this resident today, when asked about the resident's bed rail pads, the CNA stated the rail pads need to be on the bed when the resident is in the bed and the bed in low position, I have received training in the past about this resident's care. Review of the facility's policy and procedures titled, Safety/Accidents and Supervision of Residents dated 04/05/2023 states: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility wide priorities. Purpose: Each resident will receive adequate supervision and assistive devices to reduce/prevent accidents. 105252 Page 10 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow doctor's orders related to Oxygen administration for one resident (Resident #77) out of two residents who were investigated for oxygen administration. Residents Affected - Few The finding included: Observation on 07/10/23 at 11:46 AM, the Resident was lying in bed, alert and oriented, call light within reach, TV on, he stated, he gets dialysis three times a week, oxygen in place at 1.5 Liters. (Photo evidence) Observation on 07/11/23 at 10:22 AM, the Resident was not in room, the oxygen machine running and reading between 1-1.5 Liters. (Photo evidence) Observation 07/11/23 at 10:37 AM, the Resident was in a Geri chair, in the activities room, watching TV, no oxygen cannula observed at this time. Observation on 07/12/23 at 11:38 AM, the Resident was lying in bed, watching TV, the call light was within reach, no nasal cannula observed on resident, the oxygen machine was off, the resident stated, I just came back from dialysis and I'm a little tired. Record Review of Resident #77's Minimum Data Set (MDS)-Quarterly Review dated 06/05/2023, Most recent admission: [DATE], Previously admitted on [DATE], Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Section G-Functional Status revealed: Bed mobility-Total dependence, Transfer-Total dependence, Locomotion in and out of unit-Total dependence, Eating-Extensive Assistance, Toilet use-Total dependence, Bathing-Physical help in part of bathing activity, Section O- Special Treatments, Procedures, and Programs revealed: Oxygen therapy while a resident, Dialysis while a resident. Review of Resident #77's diagnoses revealed, the resident has diagnoses of but not limited to: End stage renal disease, Essential (primary) hypertension, Paroxysmal atrial fibrillation, Adult failure to thrive, Left ventricular failure, unspecified, Heart failure, unspecified, Acute and chronic diastolic (congestive) heart failure, Shortness of breath dated 12/30/2022, and Hypoxemia dated 03/22/2023. Review of the Physician's orders revealed: an order dated 03/21/2023-Check nasal cannula every shift for hygiene and skin check, Every Shift, Morning, Evening, Night, and an order dated 03/21/2023-Oxygen at 2L via nasal cannula continuously. Call MD if oxygen less than 92, Every Shift, Morning, Evening, Night. Review of Resident #77's care plan with category: Medical, start date 06/29/2023 and last reviewed/revised 06/29/2023 at 14:27 revealed, Problem: Resident requires continuous Oxygen therapy as ordered related to: Shortness of breath with Approach: Monitor Vital Signs as ordered, notify provider at once if abnormal s/s noted, Assess and document resident's respiratory status and notify provider at once if any changes in condition noted, Ensure flow rate is accurate, Observe Oxygen precautions per protocol. Change oxygen tubing weekly on Sunday and as needed. Check nasal cannula every shift for hygiene and skin check. Apply and change humidified sterile water, date bottle as needed, Apply 105252 Page 11 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Oxygen 2Liters Per Minute (LPM)/ nasal cannula continuous as ordered. Check oxygen saturation on shift if needed. Document if abnormal and notify provider at once if oxygen therapy is not effective. Review of Resident #77's vitals revealed the following: 07/10/2023 oxygen (O2) Saturation: 96%, Oxygen Use: Yes-Liter flow-2. 07/10/2023 at a11:16, O2 Saturation: 97% Oxygen Use: No, 07/10/2023 at 22:42 O2 Saturation: 98%, Oxygen Use: Yes - Liter flow-2, 07/11/2023 at 01:20, O2 Saturation: 100%, Oxygen Use: Yes-Liter flow-2, 07/11/2023 at 01:37, O2 Saturation: 100%, Activity: Resting, Location: Right Upper Digit, Oxygen Use: Yes-Liter flow-2, 07/11/2023 at 10:00, O2 Saturation: 100%, Oxygen Use: Yes - Liter flow-2, 07/11/2023 at 16:59, O2 Saturation: 98%, Oxygen Use: No, 07/12/2023 at 02:03, O2 Saturation: 100%, Oxygen Use: Yes - Liter flow-2, 07/12/2023 at 12:01, O2 Saturation: 99%, Oxygen Use: Yes - Liter flow-2. Review of progress notes revealed, a note dated 07/11/2023 at 22:45-Resident lying in bed in stable conditions, resident awake and alert. Medication given as ordered and well tolerated. Oxygen at 2 liters via nasal cannula, a note dated 07/13/2023 08:34 11-7 SHIFT: Post dialysis state satisfactory. Vitals signs stable (VSS), oxygen (O2) at 2 liters via nasal canula (n/c), O2 saturation 95 in room air, insisting on using O2, education provided, blood pressure (B/P) 144/60, Pulse 56. Left femoral dialysis catheter intact with clean dry and intact dressing, will continue to monitor. Call light at his reach. During an interview on 07/12/23 at 11:40 AM with Staff H-Registered Nurse on North Wing revealed, when asked about Resident #77's oxygen use, she stated he uses oxygen, it is continuous, he always needs it. When asked about the time Resident #77 came back from dialysis, she stated, I have to check the computer, she proceeded to check the computer and stated, I do not see it here, let me get the paper to check, I gave him his medication. Staff H went to get paper then she came back and stated, let me check the Medication Administration Record (MARs), he came at round 11:00 as I gave him hydralazine at 11:15 AM. When asked about who is in charge of placing oxygen on resident when coming back from dialysis, she stated the nurse is in charge to place the oxygen back, and he immediately calls if he needs as he is alert. When asked whether the resident had the oxygen in place at the time of the interview, she stated, if he hasn't taken it off, he has it, and sometimes we take it off for repositioning, when they come, we receive them. Surveyor asked Staff H to come to the room to check the oxygen, she entered the room and stated, he doesn't have it, where is his oxygen. Staff H proceeded to grab the nasal cannula and it dropped on the floor, then she exited the room and stated, I am going to get a new nasal cannula as the other one touched the floor. Staff H came back to the room, proceeded to place the nasal cannula on a paper towel on the resident's overbed table, she washed her hands and talked to the resident about putting on the oxygen. Asked, how many liters he needed, she stated, it has to be at 2 liters, it was off and when it is off, it falls down completely. She turned on machine and adjusted oxygen level, and placed the nasal cannula on the resident. Surveyor then proceeded to check the oxygen liters on the oxygen machine, machine stills read 1.5 liters at this time. Surveyor pointed out to Staff H about the liters on the machine and she stated, the problem is I'm looking from up top not down there. She adjusted the oxygen and had a hard time placing it to 2 liters. After surveyor intervention, review of progress notes on 07/12/23 revealed a note dated 7/12/23 with Date/Time 07/12/2023 at 11:00, Created Date 07/12/2023 at 11:47 Created By Staff H-Resident returned from dialysis procedure, stable conditions, O2 99% at room air, resident stated no need for 02 at this time. Will notify MD (Medical Doctor) for further recommendations. 105252 Page 12 of 13 105252 07/13/2023 Jackson Memorial Perdue Medical Center 19590 Old Cutler Road Cutler Bay, FL 33157

F 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 07/12/23 at 02:54 PM with Staff H-Registered Nurse on the North Wing, about the note, she stated I checked his saturation and since it was good I talked to the doctor, and she stated that it was not continuous, the oxygen, when I put the oxygen on I check, when you left I checked the saturation and it was fine. I told the doctor and I checked his saturation, she gave me a new order, this was at around 1:00, when I talked to you, and I asked him how he was feeling, he said fine. Residents Affected - Few During an interview on 07/12/23 at 03:02 PM with Staff I-Registered Nurse/Charge Nurse on North Wing. When asked about following the oxygen order for Resident #77, she stated, the nurse is in charge of checking the order, every shift for the oxygen, he went to dialysis, he goes to dialysis Monday, Wednesday, and Friday, previously his oxygen was continuous, and he is improving, and they evaluated him today, as he is doing better and we have changed the order to as needed (PRN), previously the order was at 2 Liters continuously. Staff H called the doctor that the patient is doing pretty good for the saturation, and the doctor came to see him, she was here with the nurse practitioner, she was here around noon. During an interview on 07/13/23 at 11:35 AM with the Director of Nursing (DON), when asked the protocol to follow for checking on oxygen machines to which she stated, the protocol depends on the order, if continuous, they will put it continuously or PRN when it is necessary to use, the nurse has to look at it, and see whatever the order is, then that it is. When asked about the way the oxygen machine can be read, she stated, I would think that you will be eye level, but I do not know if that is necessary, to be able to balance the flow meter at any height you should be able to see it, you do not have to be at a certain position. When asked about Resident #77's order, she stated, continuous means all the time, the order was changed, what should happen as far as that order, is concerning if they are noticing that the pulse oximetry is good or at 100%, you do not need it, they are taking the pulse oximetry all the time if there is an appropriate level, they probably don't need it. I would think they will have to bring it up to the floor, if you see that the pulse oximetry is 100% all the time, so why would he be on oxygen all the time, that is probably something we should have identified that he did not need it sooner. Review of the facility policy and procedure for Oxygen Therapy dated, 2/20/2022 revealed, The purpose of the procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physicians orders or facility protocol for oxygen administration. 105252 Page 13 of 13