Health inspection·August 15, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident number 199) out of three residents reviewed for hospital discharges. Resident number 199 was coded as being discharged to the hospital but the resident was discharged home. There were 201 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Record review of the MDS (Minimum Data Set) Assessment Completion and Accuracy Policy and Procedure (issued 9/2020) documented: Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development; Procedure: 2) The completed MDS is verified and signed by the MDS Coordinator. Staff members who complete portion of the assessment attest to the accuracy of their sections by signature and 5) The assessment will accurately reflect the resident's status. Closed record review of the Demographic Face Sheet for Resident number 199 documented the resident was admitted on [DATE] with a diagnosis of cerebral infarction, atrial fibrillation, hypertension and osteoarthritis. The resident was discharged home on 7/02/2024. Review of the Discharge Return Not Anticipated MDS (Minimum Data Set), dated 7/02/2024 for Resident number 199 documented: The discharge-return was not anticipated; It was a planned discharge; Discharge to acute hospital; discharge date was 7/02/2024. The MDS was incorrect. The resident was discharged home and not to the hospital. Review of the Physician's Order Sheet dated July 2024 for Resident number 199 documented: Discharge home on 7/02/2024 with home health services (Revision date 7/01/2024). Review of the Discharge Care Plan for Resident number 199 (written 3/27/2024) documented the resident required short term care at the facility for rehabilitation and would return to community or prior living arrangements. Review of the IDT (Interdisciplinary Team) Discharge Progress Note dated 7/02/2024 at 12:55 for Resident number 199 documented: Resident was discharged on 07/02/2024. Resident was admitted to facility for: For rehabilitation, for community re-integration. Resident being discharged to own home. Review of the Ombudsman Form dated 7/02/24 for Resident number 199 documented the resident was discharged home on 7/02/2024. The form was sent to the Ombudsman on 7/09/2024. On 8/14/24 at 9:04 AM, interview with the Social Services Director. She stated, I fax the forms to the Ombudsman weekly. For [ ] for the 7/02/2024 discharge, the form was sent on 7/09/2024. She was discharged home. On 8/14/24 at 11:25 AM, interview and record review with Staff A Registered Nurse (RN), MDS Coordinator. She stated, Discharge Return Not Anticipated MDS, dated [DATE] says she went to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105554 If continuation sheet Page 2 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The POS for July 2024 says she was discharged home on 7/02/24. The Discharge Progress note dated 7/02/24 says she went home. The MDS dated [DATE] is incorrect. On 8/15/24 at 7:32 AM, interview and record review with the Director of Nursing (DON). He stated, This patient was discharged on 7/02/24. This was a rehab patient. This patient was discharged home. The MDS Discharge Return Not Anticipated, dated 7/02/24 says the resident was discharged to the hospital. He confirmed the MDS was incorrect. Event ID: Facility ID: 105554 If continuation sheet Page 3 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review the facility failed to ensure the safety for one out of nine sampled residents as evidenced by 1) Resident #54, a vulnerable resident with orders for bilateral floor mats was observed in bed with one floor mat 2) failed to ensure three out of four soiled utility rooms were locked. There were 201 residents residing in the facility at the time of survey. The findings included: During initial observation on 08/12/24 at 08:20 AM Resident #54 was observed there in bed, there was mat on the floor to the right side of Resident #54's bed. On 08/13/24 at 09:24 AM Resident # 54 was asleep in bed and bilateral floor mats observed in place. On 08/14/24 at 07:47 AM Resident # 54 was in bed being fed breakfast and one floor mat was against the wall and one on the floor at the right side of the bed. During an interview on 08/14/24 at 09:30 AM Licensed Practical Nurse (LPN) (Staff C) stated: The resident is supposed to have two floor mats, if during rounds I see any of the resident's mats are missing and the resident is in bed I would make sure to look around the room for the other mat and put it in place, if the mats were not in the room I would call maintenance for new mats. The resident has orders for bilateral floor mats while in bed. Interview on 08/14/24 at 09:41 AM Certified Nursing assistant (CNA) (Staff D) stated: I am assigned to the resident, the resident has two floor mats, one on each side of the bed, when I do my rounds, if one of the floor mats is missing, I talk to the nurse first and then I will make sure the floor mat is put in place. Interview on 08/15/24 at 08:40 AM, the Director of Nursing (DON) revealed there is a running list of the equipment each resident should have at the nurses' station . Review of the medical records for Resident #54 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to seizures, Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of the Physician's Orders Sheet for August 2024 revealed Resident #54 had orders that included but not limited to: 8/9/24- bilateral floor mats on each side of bed every shift for safety. Record review of Resident # 54's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score-unable to be determined. Section E for Behaviors documented no behaviors exhibited. Section GG for Functional status documented resident is dependent for care. Record review of Resident #54 's Care Plans Reference Date 07/31/2024 revealed: Resident is at risk for falls and injuries related to poor sitting and standing balance, cognitive impaired and treatment with antidepressant. History of falls in the facility. Exhibits period of agitation, restlessness, hanging the legs out of bed, at risk for falls. On 7/19/24: Fall in facility, discharge to hospital for evaluation, Left forehead abrasion, right eye redness. Resident will have minimized risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105554 If continuation sheet Page 4 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some falls and fall related injury through the next review date. Interventions include- Fall in facility bilateral floor mats, mattress bolsters as indicated . Review of the facility policy and procedures titled Accidents ad Hazards dated 01/16/2019 states: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards) and risk(s) 2. Evaluating and analyzing hazard(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary. On 08/13/24 at 8:53 AM while on the second floor, Staff F, Registered Nurses (RN) was observed carrying a tied plastic bag with trash and entering the Biohazard room without using a code or key. Staff F, RN exited the Biohazard room and performed hand hygiene. When asked about the code for door to the Biohazard room, Staff F, RN stated: I opened The Biohazard room door without a code. This room is supposed to have a code. On 8/13/24 at 09:00 AM while on the ground floor, Staff G, Certified Nursing Assistant (CNA) was observed carrying a tied plastic bag with trash an entered the Biohazard room without using a code or key. After Staff G, CNA exited the Biohazard room and asked about the code to the Biohazard room; Staff G, CNA stated: I do not need a code to enter the Biohazard room. On 08/13/24 at 9:19 AM The Director of Nursing (DON) revealed; there are four biohazard rooms in the facility. each room is locked with a key or code. The doors are expected to be locked automatically once staff exit the room, the purpose for keeping it locked is for residents' safety and infection control. On 8/13/24 at 9:26 AM A tour was conducted of four out of four Biohazard rooms with the DON. On the fourth (4th) floor The DON entered the Biohazard room with a code. On the third (3rd) floor the DON entered without a code. On the second (2nd) floor the DON entered the Biohazard room without a code. On the ground floor the DON entered Biohazard room without a key. The DON then informed Maintenance staff of the issue. Record review of Policy entitled, Bio-hazardous Waste Management Plan revealed Policy: It is the policy of the facility to provide care and services related to Biohazardous waste in accordance to State and Federal regulations. Procedure: 7. The facility will provide an onsite storage area designated for Biohazardous waste. Class III FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105554 If continuation sheet Page 5 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 observation, interview and record review the facility failed to ensure medications were stored safely for one out of nine sampled residents (Resident #51). As evidenced by two ointments, one medicated powder and one cream were observed on the overbed table in Resident #51's room. The findings include: During initial observation on 08/12/24 at 07:58 AM Resident# 51 was in bed asleep, medications (creams, ointments, medicated powder) were observed on overbed table (Photo available). On 08/13/24 at 09:11 AM Resident #51 was observed in geriatric chair asleep in the room. On 08/14/24 at 08:56 AM the resident in room receiving care from Certified Nursing Assistant (CNAs) (Staff B). Review of the medical records for Resident #51 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction due to embolism of left posterior cerebral artery. Review of the Physician's Orders Sheet for August 2024 revealed Resident #51 had orders that included but not limited to: Barrier cream to sacral area and buttocks-every shift for preventative and as needed for after incontinent episodes. Record review of Resident # 51's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score (BIMS) of four out of fifteen which suggests severe cognitive impairment. Record review of Resident # 51's Care Plans Reference Dated 07/10/2024 documented: Resident has an Activities of Daily Life (ADL) Self Care Deficit & is at Risk for Complications and decline, ADLs may Fluctuate throughout the Course of Day. Requires maximum/substantial to total staff Assistance with ADL's. Interview on 08/14/24 at 09:20 AM Certified Nursing Assistant (CNA), (Staff B) stated: I am the CNA assigned to the resident, I used soap and cream to clean the resident, then apply barrier cream and medicated powder. I store the items after use away in the resident's bedside drawer. Interview on 08/14/24 at 09:24 AM Licensed Practical Nurse (LPN) (Staff C) stated: stated the barrier cream we use at the facility are single used packages that are stored at the nurses' station, sometimes the family brings items that they want us to use like a lotion or powder, we would store those items in the bed side drawer in a plastic bag. I usually do my rounds several times during my shift and if I notice anything in the patients' room that is not supposed to be there, I will make sure I take care of it (store the item, dispose of the item etc.). Interview on 08/15/24 at 08:34 AM the Director of Nursing (DON) revealed after seeing the photo of the medicated powder, cream lotion on the overbed table reported Staff B confirmed that he left the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105554 If continuation sheet Page 6 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Nursing and Rehabilitation Center 8333 W Okeechobee Road Hialeah Gardens, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 medicated powder, ointments and cream treatments on the overbed table. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Labeling of Medications, Storage of Drugs and Biologicals dated 3/2020 states: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105554 If continuation sheet Page 7 of 7