Health inspection·April 13, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, records reviews and interviews, the facility failed to ensure dignity during dining for one (Resident #90) out of 40 residents who are dependent on assistance with eating. As evidenced by one facility staff standing while feeding the resident. The findings include: In an observation on 04/10/23 at 09:12 AM, Resident #90 is dressed and in the wheelchair with eyes closed. In an observation on 04/11/23 at 08:47 AM, Staff C, a Diet Technician was observed standing while feeding resident #90 breakfast. Staff C stated, There is no chair in the room for me to sit down in and feed the resident. This resident eats pureed food and needs assistance with eating. In an observation on 04/13/23 at 08:02 AM, Resident #90 was in the wheelchair. Staff D, Certified Nursing Assistant (CNA) pulled a chair to resident #90. Staff D washed hands in the restroom. Prepared tray to serve the resident. Staff D sat in the chair to feed the resident. The meal was pureed and thickened liquids. Resident #90's left hand arm is observed to be contracted, the resident holds it to chest & the right arm is underneath the blanket. Record review of Resident #90 medical records revealed, medical diagnoses of dementia, glaucoma, Alzheimer's Disease. The diet is regular, nectar thickened liquids, pureed. In the physician orders, it states, document meals, intake and output. Point of care for meal consumption for breakfast, lunch and dinner and fluids. Fortified cereal at breakfast time. Record review of the minimum data set, quarterly review dated 2/14/23 documents, the Brief Interview of Mental Status score is a 3 meaning severe mental impairment. Rejection of care is behavior not exhibited. Bed mobility is extensive assistance with two plus assists. Transfer is total dependent with two plus assists. Eating is extensive assistance with one assist. Toileting is extensive assistance with one support. No weight loss or gain in the past month or 6 months. No swallowing disorder symptoms. No dental issues. No speech therapies. In care plan, it is noted in Activities of Daily living: Self Care Deficit, needs extensive to total assistance with activity of daily living. Diagnosis of Chronic Obstructive Pulmonary Disease, Alzheimer's, Dementia, Osteoarthritis, History of compression fracture T-12. Will not develop complication related to decline in activities of daily living by next review date. Target Date is 05/12/2023. On 04/13/23 at 09:08 AM, in an interview with the Registered Dietitian and Staff E, a Registered Diet Technician (Staff E) it was revealed, when asked about sitting with residents while assisting Page 1 of 7 105554 105554 04/13/2023 Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents to eat. The Registered Dietitian stated, We usually sit 100 percent of the time. Sometimes there are no chairs available. We can ask a staff member to bring a chair for us. Sometimes, there is a chair in the room. I was helping a resident eat the other day. The chair was hard. We may stand because we are repositioning the resident in the chair or assisting them. We know we must sit because of dignity concerns. On 04/13/23 at 12:16 PM, in an interview with the Diet Technician (Staff C). When asked about assisting residents to eat during meals. Staff C stated, My job is to assist residents with eating breakfast and lunch. I assist with the certified nursing assistant (C N A) during mealtimes. I may assist the residents in their room or in the dining room. That day that you observed me, I asked the CNA to bring me a chair to sit. The CNA did not come back to me. That's when you walked in. In some resident rooms there are chairs. I assisted the resident with eating because her roommate was eating her breakfast. I didn't want to leave her without her eating her breakfast. I'm aware that we are to sit down with the residents during meals. On 04/13/23 at 01:20 PM, in an interview with the Director of Nursing (DON) revealed, when was asked about how staff can get chairs during mealtimes to assist the resident with eating. The DON stated, They are in the activity area and dining room. Staff know to sit down as it is a dignity issue and respect to the patient. To be at the same eye level. We have had in-services on that in the past. Speech therapy has given in-services for how to assist residents while eating in the past month. Review of the facility's Policy and Procedure titled, Promoting/Maintaining resident dignity during mealtime issued on 3/2020. On guideline number six it states, All staff will be seated, if possible, while feeding a resident. In the policy and procedure for resident rights dated 3-1-2021. In 30-A it states, promoting resident independence and dignity in dining (such as avoidance of disposable utensils and dishes, using bibs instead of napkins, dining room conducive to pleasant dining). 105554 Page 2 of 7 105554 04/13/2023 Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016

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 physician orders for oxygen therapy as prescribed for one (Resident #118) out of 3 residents sampled. Residents Affected - Few The Findings Included: During observation on 04/10/2023 at 08:56 AM, Resident #118 was observed sitting in the wheelchair in the room, the oxygen (02) was running at 3 liters per minute (LPM), via nasal cannula, the 02 tubing observed was not dated, no dated supplies were observed around the 02 concentrator. On 04/11/23 at 08:46 AM, Resident #118 was observed in the room in the wheelchair watching television, there was no 02 running, stated today is a great day, 02 tubing observed in a plastic bag dated 4/10/23. On 4/12/23 at 10:30AM, Resident #118 was observed in the Activities room fixing puzzles with other residents, no distress was noted. Review of the medical records for Resident #118 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Chronic respiratory failure with hypercapnia, Chronic obstructive pulmonary disease unspecified (COPD), Obstructive sleep apnea (adult), Pneumonia unspecified organism and Influenza due to other identified influenza virus with other respiratory manifestations. Review of the Physician's Orders Sheet for April 2023 revealed, Resident #118 had orders that included but were not limited to: From 2/06/22-4/11/23-Oxygen @ 2L/m via nasal cannula as needed. From 04/11/23 oxygen at 2-3LPM via nasal cannula as needed. Medications included: Budesonide suspension for nebulization; 0.5 milligram (mg)/2 milliliter (mL) inhalation twice A Day for Shortness of breath. Ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL- inhaled content of one vial for 15 minutes every six hours while awake for COPD. Bilevel Positive Airway Pressure (BiPAP) machine at night and as needed (PRN) with settings 18/8/ 35%, backup rate 12 beats per minute (bpm) on at bedtime and off in the morning while awake and PRN. Record review of Resident #118 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) is 15, indicating the resident is cognitively intact. Section G for Functional Status documented resident requires supervision for eating and extensive assistance with all other Activities of Daily Living (ADLS). Section J for Health Conditions documented resident experiences Shortness of breath or trouble breathing when lying flat. Section O for Treatments and Procedures documented resident received oxygen therapy in the last 14 days. Record review of Resident # 118's Care Plans Reference Date 04/12/2023 revealed, Resident has potential for difficulty breathing related to COPD, and Respiratory Failure. Multiple hospitalizations related to respiratory diagnosis. Interventions included but were not limited to: BIPAP as ordered by physician (MD), Maintain precautions/care as indicated. Respiratory Therapy Evaluation and Treatment as indicated. Nebulizer/Inhalation Treatment as indicated. Maintain precautions/care as per MD orders. 105554 Page 3 of 7 105554 04/13/2023 Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of the Physician progress notes for Resident #118 dated 04/07/23 timestamped 15:23 documented, Patient with several hospitalizations in the last year for her COPD. Currently in no acute exacerbation. Doing great on BiPAP machine at night as recommended. She was found in the hall, with no acute distress, conversational, at room air sating above 94%. Continue using BiPAP and nasal cannula as needed as oriented, as well all her nebulizer treatment. Residents Affected - Few During interview on 04/11/23 at 03:46 PM, the Director of Nursing (DON) stated, when asked about care orders for oxygen tubing, the DON stated our policy states, we change the tubing weekly and as needed, we do not need an order. When asked who informs the direct care staff about this policy, the DON stated the nurses are aware of the policy and we have a respiratory therapist on site. Regarding oxygen orders, the DON stated all the continuous oxygen orders are prescribed at 2-3 Liters per minute, the as needed oxygen orders for residents are specific, but we will look into changing those orders. The Surveyor informed the DON of the observation findings concerning Resident # 118 oxygen observed at 3LPM and no dates on tubing to show when the last time it was changed. The DON acknowledged the observation findings and stated he will be working with his nurses to continue to improve patient care and do in-services. Interview on 04/12/23 at 10:01 AM, a Registered Nurse on the 2nd floor (Staff A) stated, when asked about the care of oxygen tubing for residents, she stated, she changes the residents' oxygen tubing once a week and as needed. Asked if there was an order on the Treatment Administration Record (TAR) to sign off when they change the tubing, and the nurse was not sure if there were any specific orders that they would sign off on. Staff A stated, she will check with her supervisor and let the surveyor know. Interview on 04/12/23 at 11:00 AM, a Registered Nurse on the 2nd floor, (Staff B) when asked about the care of oxygen tubing stated, she changes the residents' oxygen tubing as needed. Review of the facility's policy and procedure titled, Standards and Guidelines: SG Respiratory Care and Oxygen Administration revised 10/2022 states: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Step 1. verify that there is a physician's order for respiratory procedures or oxygen use. Step 10. Oxygen, trach and nebulizer tubing is changed weekly and dated as verification that the tubing was changed. Tubing order may be recorded in the clinical record, but it is not required. The Facility failed to follow the physician order for oxygen and changing tubing for Resident #118. 105554 Page 4 of 7 105554 04/13/2023 Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns as evidenced by not implementing an effective plan of action to correct identified quality deficiencies in problem-prone areas, related to respiratory/tracheostomy care and suctioning as evidenced by repeated deficient practice during consecutive annual surveys. Cross reference F695 Respiratory/Tracheostomy Care and Suctioning. The facility had deficient practice during the last recertification survey conducted in 2022. The facility had a census of 191 residents at the time of the survey. The findings included: Record review of the facility's survey history revealed, during the annual survey exit dated 01/03/2022, deficient practice was cited related to F 695- Respiratory/Tracheostomy Care and Suctioning. F 695 was also cited during the current annual recertification survey exit dated 04/13/2023. Review of the facility's plan of correction for the last annual survey with an exit date 01/03/2022 related to F 695 Respiratory/ Tracheostomy Care and Suctioning indicated as part of the correction measures revealed that A facility wide audit was conducted of all residents requiring Respiratory Services (Oxygen) to ensure residents Oxygen therapy via Nasal Cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery and frequency. Licensed Nurses were re-educated by DON/designee on Quality of Care: Respiratory Care/Orders. Following MD orders when providing Respiratory Care/Oxygen. During an interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 04/13/2023 at 01:57pm it was revealed, the Risk Manager and Quality Assurance Performance Improvement (QAPI) Committee meets once a month on the third Thursday each month. The Committee is the NHA, DON, ADON, the Medical Director, the Social Services Director, Infection Preventions, Minimum Data Set (MDS), Restorative Nursing, Human Resources (HR,) Dietitian, Plant Operations, Activities Director, Rehabilitation Director, and Environmental Services Director. The NHA stated they always get the Qualtity Assurance Performance Improvement (QAPI) reports from Pharmacy, Nephrologist services, and Diagnostic companies contracted with facility, but they do not come every month. The NHA stated there are several ways for the committee to have access and identify concerns and mentioned grievances, any other concern discussed with residents and/or family, staff and the Safety Committee which is integrated by the certified nurse assistants (CNAs, Nursing, Maintenance, Housekeeping, Dietary). They stated they review any concern or incident brought by the Maintenance Department to the committee, and reports taken from the Resident Council that is brought up by Activities and/or Director of Social Services (DSS). The NHA stated they receive concerns brought by Human Resources (HR) and they do hold townhall meetings monthly before QAPI and the QAPI Committee can get the reports and concerns from other sources different to QAPI members and the Safety Committee. The NHA stated they also look at the Certification and Survey Provider Enhanced Reports (CASPER) reports surveys. The NHA revealed the different performance improvement plans (PIP) the facility has opened and have all of them ongoing (without mentioning any PIP for the deficient practice cited related to Respiratory/Tracheostomy Care and Suctioning, she explained how the ongoing process is to measure effectiveness of their intervention. During the interview DON stated there is not an open PIP for F 695 at this time. When asked about 105554 Page 5 of 7 105554 04/13/2023 Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the deficiency found regarding oxygen treatment which was cited in the previous annual survey, The DON explained they started doing in service with nursing staff immediately after he was made aware of it, and staff received one to one service to make sure the oxygen level follows the doctor's order and staff will be triple checking the orders. The DON stated he spoke with the doctor and explained the patient (Resident #118) can be up to three liters per minute, and he gave a new order, and they updated the care plan. When asked about the effectiveness of their QAPI regarding the previous cited deficiency, the DON stated before this survey the physician's orders were change to the 2-3 liters per minute for all continuous medication, but they did not change the PRN order which was done now. Review of QAPI meetings signing sheet dated 01/23/2023, 02/23/2023, 03/23/2023 reviewed and revealed no concerns. The facility's QAPI Committee met monthly. Reviewed QAPI Program issued 06/10/2021 revealed: 11. Governance and leadershipb. Governing oversight responsibilities included, but are not limited to the following: iii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities. vi. Ensuring that corrective actions address gaps in systems and are evaluated for effectiveness. Review Policy and Procedures on QAPI effective date 10/02/2019 revealed: PURPOSE STATEMENT: To provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility. POLICY STATEMENT: It is the intent of this facility to conduct an ongoing Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate, and improve the quality and appropriateness of resident care. QAPI supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improvement the organization's overall performance. GUIDELINES: 6.- The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. 7. The QAPI committee will review and coordinate audits and assessments based on the QAPI calendar. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. Criteria for selecting additional aspects of care for performance improvement are based on the following: 105554 Page 6 of 7 105554 04/13/2023 Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016

F 0867 d. Problem areas-the aspect of care has tended in the past to produce problems for staff or residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105554 Page 7 of 7