Health inspection·March 22, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room and placed on her bedside table. Her roommate, Resident #46, did not receive her lunch tray at the same time. Resident #46 lunch tray came into the room at 1:30 PM, which was about 23 minutes later. An interview conducted on 03/22/23 at 9:30 AM with Staff I, CNA, who stated that the facility educated them regarding dignity during dining. She was told she needed to sit at an eye level while assisting residents with their meals. An interview conducted on 03/22/23 at 10:05 AM with the Unit Manager who stated the staff is supposed to bring trays into residents' rooms, one room at a time, but it is often not done. The three carts come from the kitchen to the Unit, and those trays are not in order per room, so trays are sometimes not given to two residents simultaneously if they are in the same room. 2. Resident #9 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident #9 had a medical history to include Muscle Weakness, Musculoskeletal Deformities, Contractures, Epilepsy / Convulsions, Spastic Paraplegia, Cerebral Palsy, Microcephaly, Intellectual Disabilities and COVID-19. A Quarterly Minimum Data Set (MDS) was completed on 02/08/23 that documented Resident #9 had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident had severe mental impairment. This MDS also documented Resident #9 was totally dependent on 2 or more staff members for eating meals. Review of Resident #9's care plans revealed there was a care plan in place regarding the resident being at risk for loss of range of motion both upper arms related to physical limitations, disease process of cerebral palsy. This indicated that Resident #9 was unable to feed herself her meals. During the initial meal observation conducted at the facility on 03/19/23 at 1:28 PM, the surveyor observed a staff member assisting Resident #9 with her lunch meal. Resident #9 was partially reclined in a chair in her room and the staff member was standing over the resident, assisting her with her lunch meal. A Resident Council Meeting was conducted on 03/21/23 at 11:00 AM. In attendance for this meeting were 13 residents, including the Resident Council President and [NAME] President. During this meeting, the surveyor asked the residents about meal trays being served. Many residents voiced concerns regarding dignity with dining issues. Many residents reported that their meal trays are not delivered at the same time as their roommate. They stated they often have to wait for 10 to 20 minutes for their tray to be delivered while their roommate eats. They stated this makes them feel that the staff does not consider how they feel. They stated it makes them feel uncomfortable while they are smelling their roommate's food and watching them eat, waiting for their own tray. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 2 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to follow tube feeding orders as per physician's orders for 1 of 1 sampled resident reviewed for tube feeding (Resident #62). The findings included: Resident #62 was admitted on [DATE] with diagnoses to include Dysphagia, Altered mental status, and Muscle Weakness. The physician order, dated 02/16/23, documented for enteral feeding with Jevity 1.5 (tube feeding formulary) at 70 milliliters (ml) an hour for 20 hours off at 10:00 AM and on at 2:00 PM. The order, dated 02/09/21, was noted for regular diet mechanical soft texture. An observation conducted on 03/19/23 from 12/30 PM to 2:00 PM did not show that Resident #62 received any food for lunch. In an observation conducted on 03/20/23 at 9:00 AM, Resident #62 was in his room eating his breakfast tray with Staff B, Certified Nursing Assistant (CNA), feeding him the lunch meal. Closer observation showed the tube feeding was still running with Jevity 1.5 at 70 ml an hour while getting fed by Staff B. The tube feeding bottle was started at 4:00 AM on 03/20/23. The bottle was noted at the 850 ml mark out of a 1000 ml capacity bottle. The tube feeding that was started at 4:00 AM should have been at the 650 ml mark. In this observation, Resident #62 started vomiting, and Staff B stopped feeding Resident #62 and called the nurse to come into the room. The nurse came into the room and turned off the tube feeding. In this observation, Staff B reported that Resident #62 does not eat his meals and that he told her that he was full this morning during breakfast. In an observation conducted on 03/20/23 at 3:00 PM, the tube feeding was noted running in the room at 70ml/hr. Close observation showed that it was at the 800 ml mark out of the 1000 ml capacity bottle. In an observation conducted on 03/21/23 at 9:09 AM, Resident #62 was noted in his room with the tube feeding running at 70 ml an hour. Closer observation showed the bottle was started at 2:00 AM on 03/21/22. The tube feeding was noted at the 800 ml mark out of a 1000 ml capacity bottle. A tube feeding that was running at 70ml an hour should have been around the 500 ml mark out of a 1000 ml bottle. Resident #62 Minimum Data Set, dated [DATE] showed that a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The care plan dated 02/03/23 showed Resident #62 was dependent on tube feeding and to follow Physician's orders for current feeding orders. The progress note dated 03/21/23, completed by the facility's Clinical Dietitian, showed that Resident #62's diet was changed to regular mechanically altered thin liquids with a pleasure meal at lunchtime. It further showed Resident #62 was refusing all his meals and will continue with current enteral feeding as the primary source of nutrition. It further showed Resident #62 is tolerating his tube feeding. The Speech Therapy Evaluation dated 03/21/23 showed that nursing reported that Resident #62 was with poor appetite and intake, and needs enteral feeding for primary means of nutrition and hydration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 3 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0693 at this time. Level of Harm - Minimal harm or potential for actual harm In an interview conducted on 03/22/23 at 9:10 AM with Staff C, Registered Nurse, she stated that when a resident is receiving tube feeding and is also on a diet, the tube feeding needs to be on hold while the resident is eating his meals. She further said, the resident is going to be full of the tube feeding while trying to eat his meals. Residents Affected - Few In an interview conducted on 02/22/23 at 11:40 AM, the facility's Clinical Dietitian stated the tube feeding that was started on 03/21/23 at 2:00 AM should have been at least half given by the time it was observed by the surveyor at 9:00 AM. She further acknowledged that the tube feeding was not meeting Resident's #62 nutritional needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 4 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliation was accurate for 3 of 6 sampled residents reviewed during the controlled substance record review at the facility's 2 [NAME] wing, for Residents #10, #30 and #44. The findings included: Review of the facility's policy, titled, Preparation and General Guidelines-Controlled Substances, revised on 01/2018, documented: .when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the medication administration record (MAR): date and time of administration .initials of the nurse administering the dose, completed after the medication is actually administered . 1. Review of Resident #10's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE], and diagnoses that included Hemiplegia, Obesity, Schizoaffective Disorder, Pain to left shoulder, Non-Traumatic Acute Subdural, Dementia, Bipolar Disorder and Major Depression. Review of Resident #10's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating the resident had no cognition impairment. The assessment documented under Functional Status the resident needed limited assistance with her activities of daily living (ADLs) from the facility's staff. Review of Resident #10's physician order dated 02/01/23 documented, Percocet 5-325 mg (milligrams) give one tablet every 8 hours as needed for pain. On 03/21/23 at 10:36 AM, a side-by-side review of Resident #10's medication monitoring control record for controlled substance Percocet 5-325 mg was conducted with Staff G, Licensed Practical Nurse (LPN). The review revealed one tablet of Percocet was removed from the controlled substance box on 03/06/23 at 9:31 PM (2131 hours). On 03/21/23 at 10:54 AM, a side-by-side review of Resident #10's March 2023 Medication Administration Record (MAR) was conducted with the Unit Manager (UM). The review revealed Percocet 5-325 mg had been removed from the controlled substance box on 03/06/23 at 9:31 PM was not documented or initialed by the administering nurse in the resident's MAR. The UM was asked if there was a possibility that it was documented in any other place in the record and stated there was no other place that it was documented. The UM stated the nurse had to document it on the MAR. Further review of Resident #10's medication monitoring control record for controlled substance revealed that Percocet 5-325 mg was removed on 03/03/23 at 9:40 PM (2140 hours). Review of the resident's MAR for 03/03/23 lacked the administering nurse's initials for Percocet 5-325 mg removed on 03/03/23 at 9:40 PM. 2. Review of Resident #30's clinical record documented an initial admission to the facility on [DATE] with no readmissions, with diagnoses that included Hemiplegia, Generalized Idiopathic Epilepsy and Cerebral Infarction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 5 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #30's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a BIMS score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed supervision with his ADLs from the facility's staff. Review of Resident #30's physician order dated 02/01/23 documented, Tramadol 50 mg give 50 mg every 8 hours as needed for pain. On 03/21/23 at 10:40 AM, a side-by-side review of Resident #30's medication monitoring control record for controlled substance Tramadol 50 mg was conducted with Staff G, LPN. The review revealed one tablet of Tramadol 50 mg was removed from the controlled substance box on 03/17/23 at 9:00 PM (2100 hours). On 03/21/23 at 10:58 AM, a side-by-side review of Resident #30's March 2023's MAR was conducted with the UM. The review revealed Tramadol 50 mg was removed from the controlled substance box on 03/17/23 at 9:00 PM (2100 hours) and was not documented or initialed by the administering nurse in the resident's MAR. The UM stated there was no other place that it was documented. The UM stated the nurse had to document it on the MAR. Further review of Resident #30's medication monitoring control record for controlled substance revealed that Tramadol 50 mg was removed on 03/10/23 at 8:30 PM (2030 hours). Review of the resident's MAR for 03/10/23 lacked the administering nurse's initials for Tramadol 50 mg removed on 03/10/23 at 8:30 PM. 3. Review of Resident #44's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE], with diagnoses that included Multiple Sclerosis, Crohn's Disease, Atherosclerosis Heart Disease, Chronic Kidney Disease, Major Depression and Dementia. Review of Resident #44's Minimum Data Set (MDS) 5 days admission assessment dated [DATE] documented a BIMS score of 13 indicating the resident had moderate cognition impairment. The assessment documented under Functional Status the resident needed supervision with his activities of daily living from the facility's staff. Review of Resident #44's physician order dated 01/31/23 documented, Tramadol 50 mg give one tablet every 6 hours as needed for pain. On 03/21/23 at 10:45 AM, a side-by-side review of Resident #44's medication monitoring control record for controlled substance Tramadol 50 mg was conducted with Staff G, LPN. The review revealed one tablet of Tramadol 50 mg was removed from the controlled substance box on 03/11/23 at 11:00 PM (2300 hours). On 03/21/23 at 11:00 AM, a side-by-side review of Resident #44's March 2023's MAR was conducted with the UM. The review revealed Tramadol 50 mg was removed from the controlled substance box on 03/11/23 at 11:00 PM (2300 hours) and was not documented or initialed by the administering nurse in the resident's MAR. The UM stated there was no other place that it was documented. The UM stated the nurse had to document it on the MAR. On 03/21/23 11:01 AM, an interview was conducted with Staff G, LPN, who stated the controlled substances, once administered, the nurses are to document or initial it on the resident's MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 6 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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** 3. Review of the facility's policy, titled, Administering Medications, revised on 04/19, documented .residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . On 03/19/23 at 1:05 PM, an observational tour was conducted at the facility's 2-West wing. Observation revealed a box of OTC medication, Earwax Removal kit, on top of Resident #25's night stand. The resident was not in the room during the tour. Photography Evidence Obtained. Review of Resident #25's clinical record documented an initial admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included End Stage Renal Disease (ESRD) dependence on renal dialysis, Hemiplegia, Diabetes Mellitus, Hypertension, Weakness, Malignant Neoplasm of Stomach, Schizoaffective Disorder, Major Depression and Lower Abdominal Pain Unspecified. Review of Resident #25's Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating no cognition impairment. The assessment documented under Functional Status the resident needed limited to extensive assistance with her activities of daily living from the facility's staff. Review of Resident #25's care plans lacked evidence of a care plan initiated for the resident to do self-administration of medications. Review of Resident #25's physician's order dated 02/18/23 documented, Lidocaine Pain Relief 4% apply to right parasternal area topically one time a day for pain and remove per schedule. Further review revealed no physicians order for Biofreeze roll on application and no physician order for self-administration of medications. Review of Resident #25's March 2023 Medication Administration Record (MAR) documented Lidocaine pain relief patch was applied every morning at 9:00 AM and removed at 20:59. On 03/20/23 at 9:25 AM, observation revealed a box of OTC, Earwax Removal kit, was not on top of Residents 25's nightstand. An interview was conducted with the Unit Manager who stated the resident went to the dialysis unit. On 03/21/23 at 11:35 AM, observation revealed Resident #25 was not in her room. Further observation revealed a bottle of roll on Bio Freeze on top of Resident #25's table. A side-by-side review of the bottle of Biofreeze in the resident's room was conducted with Staff G, Licensed Practical Nurse (LPN). Staff G stated the resident was not supposed to have the Biofreeze bottle in her room. Staff G added the facility did not carry the roll on Biofreeze, rather the gel type. During the review, photographic evidence of the OTC Earwax removal kit noted on 03/19/23 on top of the Resident #25's night stand, was presented to Staff G. Staff G stated the resident was not supposed to have that in her room and added the resident cannot do the earwax removal on her own because she had paralysis of one side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 7 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 On 03/21/23 at 12: 35 PM, a joint interview was conducted with Resident #25 and Staff G, LPN. The resident stated that she used the Biofreeze for her chest and shoulder pain and she bought it online. The resident was asked for the Earwax removal kit that was on top of her night stand and stated she gave it to her daughter. The resident was asked if she had more OTC medications in her room and pointed to her dresser drawer. Observation revealed Staff G opened up the drawer and found one unopened box of a roll on Asper creme with Lidocaine, one unopened jar of Pain Relief Cream and one opened box of Vapor Pads (Steam inhaler pads) with an expiration date on 04/30/22. Staff G stated the resident was educated many times that she was not allowed to have medications in her room. On 03/21/23 at 11:52 AM, an interview was conducted with the Unit Manager who stated that Resident #25 was not assessed to do self-administration of medications. On 03/22/23 at 10:26 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator, who stated that Resident #25 did not have a care plan for self-administration of medications because she was not aware the resident had medications in her room. 4. Review of the facility's policy, titled, Medication Storage in the Facility, with a revised date of January 2018, included the following: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility's policy, titled, Administering Medications, with a revised date of April 2019, included the following: Residents may self-administrate their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Record review for Resident #74 revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Acute Bronchitis, Dependence on Renal Dialysis, Major Depressive Disorder, and Cognitive Communication Deficit. Review of Section C of the MDS dated [DATE] documented Resident #74 had a BIMS score of 14, which indicated cognition was intact. Review of Section G of the MDS dated [DATE] documented Resident #74 had a bed mobility self-performance of limited assistance with support of one-person physical assist, transfer self-support of extensive assistance with support of two plus persons physical assist, dressing self-performance of extensive assistance with support of one-person physical assist, eating self-performance of supervision with support of setup help only, toilet use self-performance of extensive assistance with support of two plus persons physical assist, and personal hygiene with self-performance of supervision with support of setup help only. Review of the physician's orders for Resident #74 did not reveal an order for the resident to self-administrate medications. Review of the care plans from 02/24/23 to 03/16/23 revealed no care plan for self-administration of medications. Upon approaching Resident #74's room on 03/20/23 at 8:45 AM, an observation was made of Staff J Licensed Practical Nurse (LPN), at the medication cart outside Resident #74's room. The door to the resident's room was closed. Upon entering the resident's room at 8:45 AM, an observation was made of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 8 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 the resident sleeping in his bed and on the overbed table next to the resident was a medication cup with numerous pills. Photographic Evidence Obtained. On 03/20/23 at 8:48 AM, Staff J LPN entered the resident's room with a spoon in her hand. During an interview conducted on 03/20/23 at 8:46 AM with Staff J, when asked if she had left the medications at the bedside unattended, she stated yes, I thought the door was open and I just went to get a spoon. Staff J LPN proceeded to wake the resident to take his medications. Based on observations, interviews and record reviews, the facility failed to secure medications at the bedside for 3 of 3 sampled residents, Residents #94, #74 and #25; and failed to secure medications in the unlocked dialysis room. The findings included: 1. During the initial tour of the facility conducted on 03/19/23 at 9:12 AM, the surveyor noted that the door of the dialysis room on the first floor was unlocked. The Dialysis Room was located across the hallway from the main dining room on the 1st floor (where activities were held for the residents during the week of survey) and was on the same hallway as the DON's office and Human Resources. Observations at various times during the 4-day survey revealed residents and staff walking through that area. a. The surveyor toured the dialysis room and found a 7-drawer storage container-sitting on top were ExSept exit site skin and wound cleanser (dated 03/14/23), Alcavis disinfectant (dated 03/15/23), and an open tube of Bacitracin gel (not dated). Inside one of the drawers of this storage container were dozens of 10 milliliter (mL) prefilled Normal Saline flushes. A cardboard box was noted sitting on a chair-inside were 2 liter bags of Normal Saline. b. Cabinets were noted above a computer desk area. Inside the first cabinet were the following: 3 boxes of Heparin 30,000 units/30mL vials (a very potent blood thinner), 1 box of Vancomycin Hydrochloride 1 gram vials (an antibiotic), 1 box of Clindamycin 600milligram (mg) per 4mL vials (an antibiotic), 3 bottles of Calcitriol tablets (a Vitamin D supplement), 3 bottles of Cinacalcet tablets (a calcium reducing medication), 1 bottle of Extra Strength Tylenol tablets, 1 box of Sodium Ferric Gluconate Complex 62.5mg per 5mL vials (an iron supplement), and 1 box of 3mL syringes with needles. c. Inside the second cabinet were approximately a dozen liter bags of Normal Saline. Photographic evidence obtained. An interview was conducted with the Administrator on 03/19/23 at 9:30 AM. She confirmed that there were no dialysis employees in the facility on Sundays. The surveyor then showed the Administrator the unlocked dialysis room. She stated she did not know what time dialysis had ended on 03/18/23 (Saturday) but she agreed that the room is supposed to be kept locked when not in use. The surveyor showed the Administrator the areas of concern regarding the medications found in the room. She agreed this was a problem and stated she would discuss the findings with the dialysis staff. During another tour of the facility conducted on 03/21/23 (Tuesday) at 5:09 PM, the surveyor noted that the door of the dialysis room on the first floor was unlocked again. The surveyor immediately alerted the facility Director of Nursing (DON) and the Corporate Nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 9 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 The DON confirmed the dialysis staff were responsible for ensuring the dialysis room was locked after their work was for the day. The surveyor showed the DON and Corporate Nurse the areas of concern regarding the unattended and unlocked medications, same as were observed on 03/19/23. During this secondary observation, the surveyor also found blood tubes in a Ziploc bag in the tall white cabinet which contained resident information on printed labels along with 4 vials of resident blood which contained resident information on printed labels stored in the refrigerator. The DON immediately went to the Administrator to obtain a key to lock the dialysis room and the Corporate Nurse stayed in the dialysis room until the DON returned. 2. Review of Resident #94's medical record revealed she had been originally admitted to the facility on [DATE] and was sent to the hospital last on 03/16/23 due to chest pain. Resident #94 had diagnoses to include End Stage Renal Disease (on Dialysis), Stroke, Hypertension, Diabetes, Peripheral Vascular Disease, Anemia, Heart Disease, Malnutrition, Encephalopathy, Cataract. Review of the last Quarterly Minimum Data Set (MDS) completed on 02/24/23, revealed Resident #49 had a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. There was no documentation found indicating Resident #94 was assessed for safe self-administration of medications. Review of Resident #94's physician orders revealed there were no active orders for Hydrocortisone cream or Skin Protectant in the chart. There was no care plan in place about Resident #94 being safe to self-administer medications. During the initial tour of the facility conducted on 03/19/23 at 11:30 AM, it was noted that Resident #94 was not at the facility, but her belongings were still in the room. Resident #94's roommate confirmed Resident #94 had been out to the hospital for the last few days. The surveyor observed over-the-counter (OTC) medications that were being stored in a vase on the resident's dresser. There was a package of Hydrocortisone Cream 1%, two packets of Hydrocortisone Acetate 1% Cream, and one packet of PeriGuard Skin Protectant. Photographic evidence obtained. An observation was conducted on 03/20/23 at 9:10 AM of Resident #94's room. The roommate confirmed that she was still out to the hospital, but the OTC medications remained in the vase on the dresser. An observation was conducted on 03/22/23 at 9:20 AM with the DON of the medications in Resident #94's room. The DON confirmed that Resident #94 had been out to the hospital since the prior week and that she had been unaware of the OTC medications which were kept in the vase. The DON stated she was going to remove the medications from the vase and dispose of them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 10 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility needed to follow its menus to meet the nutritional needs of the residents observed during the main kitchen tray line observation. The findings included: A review of the Week 1 Day 3 Dinner Menu showed the following foods and portion sizes: for the regular diet, provide 8 ounces of Turkey [NAME]; for the L 2 mechanical altered diet, provide two #8 (4 ounces) scoops of the Turkey [NAME], and for the L 1 Puree diet provide two #8 scoops of the Turkey [NAME]. An observation of the tray line conducted on 03/21/23 at 4:35 PM showed the following: Staff E, Cook, was observed plating the following: 4 ounces of Turkey (not the 8 ounces as required) for a regular diet plate, one scoop of the #8 Turkey (not the two scoops of the #8 as required) for the L 2 mechanical altered diet, and 1 scoop of the #8 Turkey (not the two scoops of the #8 as required) for the puree diet plate. Continued observation showed that Staff E plated two more of the #8 Turkeys for the puree diet plate and two other of the #8 turkey for the L 2 mechanical altered diet. An interview conducted on 03/21/23 at 5:00 PM with Staff D, Dietary Manager, who stated that Staff E is still learning the serving sizes on the daily menus and was probably nervous when observed on the tray line. She further acknowledged the serving sizes were incorrect and that it is 8 ounces of turkey on the regular diet, two #8 scoops of turkey for the L 2 mechanical altered diet, and two #8 scoops of the turkey on the pureed consistency diet. In an interview conducted on 02/22/23 at 10:00 AM with the facility's Administrator, she was told of the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 11 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #25's clinical record documented an initial admission to the facility on [DATE] and a readmission on [DATE]. The resident diagnoses included End Stage Renal Disease (ESRD) dependence on renal dialysis, Hemiplegia, Diabetes Mellitus, Malignant Neoplasm of Stomach, and Lower Abdominal Pain Unspecified. Review of Resident #25's Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Status the resident needed supervision with eating activity from the facility's staff. Review of Resident #25's physician order dated 02/11/23 documented, Regular Diet, Mechanical Soft Texture. On 03/19/23 at 1:04 PM, observation revealed Resident #25 in the dining room eating lunch accompanied by two other random residents. Resident #25's meal ticket documented Mechanical Soft diet. Further observation two large pieces of raw lettuce on the resident's plate. Resident #25's diet did not allow for raw lettuce. Based on observations, record reviews, and interviews, the facility needed to follow its menus to meet the nutritional needs of the residents observed during the main kitchen tray line observation; and failed to provide the correct diet consistency per physician's orders for 4 of 4 sampled residents reviewed during dining observations (Resident #54, Resident #49, Resident #1, and Resident #25). The findings included: 1. A review of the Week 1 Day 3 Dinner Menu showed the following foods and portion sizes: for the regular diet, provide 8 ounces of Turkey [NAME]; for the L 2 mechanical altered diet, provide two #8 (4 ounces) scoops of the Turkey [NAME], and for the L 1 Puree diet provide two #8 scoops of the Turkey [NAME]. An observation of the tray line conducted on 03/21/23 at 4:35 PM showed the following: Staff E, Cook, was observed plating the following: 4 ounces of Turkey (not the 8 ounces as required) for a regular diet plate, one scoop of the #8 Turkey (not the two scoops of the #8 as required) for the L 2 mechanical altered diet, and 1 scoop of the #8 Turkey (not the two scoops of the #8 as required) for the puree diet plate. Continued observation showed that Staff E plated two more of the #8 Turkeys for the puree diet plate and two other of the #8 turkey for the L 2 mechanical altered diet. An interview conducted on 03/21/23 at 5:00 PM with Staff D, Dietary Manager, who stated that Staff E is still learning the serving sizes on the daily menus and was probably nervous when observed on the tray line. She further acknowledged the serving sizes were incorrect and that it is 8 ounces of turkey on the regular diet, two #8 scoops of turkey for the L 2 mechanical altered diet, and two #8 scoops of the turkey on the pureed consistency diet. In an interview conducted on 02/22/23 at 10:00 AM with the facility's Administrator, she was told of the findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 12 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. a. Resident #49 was admitted on 09/2022 with diagnoses to include Muscle Weakness and Acute / Chronic Respiratory Failure. Review of the Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 13, indicating cognition was intact. The physician ordered diet, dated 09/21/22, noted for regular diet mechanical soft texture. Resident #1 was admitted on [DATE] with diagnoses of cerebral infarction and dysphagia. Review of the MDS dated [DATE] showed a BIMS score of 09, indicating moderate cognitive impairment; and for eating documented supervision with set up only. Review of the physician ordered diet, dated 02/09/21, noted for regular mechanical soft diet. In an observation conducted on 03/19/23 at 12:40 PM, in the main dining room on the second floor, 12 residents were noted in the main dining room eating their lunch meal. Closer observation showed that Resident #49 was eating her lunch meal. The tray was noted with a mechanical soft diet that had chopped turkey, beans, and a cup of fresh grapes that were about 2 inches each in size. Resident #49 was observed sharing her fresh grapes with Resident #1. Resident #1 was observed eating the fresh grapes. b. Resident #54 was admitted on [DATE] with diagnoses to include Dysphagia, Altered Metal Status and Metabolic Encephalopathy. Review of the MDS 02/10/23 showed severe cognitive impairment; and for eating, the resident needed extensive assistance with one person assist. Review of the physician ordered diet, dated 11/10/20, noted for soft mechanical texture. In an observation conducted on 03/19/23 at 9:10 AM, Resident #54 received her breakfast meal. The meal ticket showed a mechanical soft diet order. The tray was noted with scrambled eggs and a stiff and stale, large piece of an English muffin. The continued observation did not show any staff in the room to assist Resident #54 with her breakfast meal. An interview conducted on 03/20/23 at 2:00 PM with the facility's Clinical Dietitian who stated there are two types of a mechanical soft diet: a mechanical soft diet and the 2nd is a mechanically altered diet. When asked if you can serve a large piece of English muffin on a mechanical soft diet, she said no; and when asked if you can serve fresh grapes on a mechanical soft diet, she also said no. The Clinical Dietitian provided a list of foods that were allowed and not allowed on the mechanically altered diet and the Dysphagia Advanced diet. She said the facility follows these two types of diet consistencies. A review of the mechanically altered diet of foods allowed and not allowed provided by the facility's Dietitian showed the following: foods to avoid are slices of bread, toast, fresh or frozen fruits, and cooked fruits with the skin or seeds. A review of the dysphagia advanced diet foods allowed and not allowed showed the following: foods to avoid are dry bread, roast, fresh fruits with tough peels, such as grapes and other dried fruits unless cooked. A review of the facility Week 1 Day 1 menu that was served for breakfast on 03/19/23 showed that under the L3 Mechanical soft diet, there is no English muffin. Under the L2 mechanical altered diet, it showed to provide Slurry English muffin. In an interview conducted on 03/22/23 at 9:00 AM with Staff D, Kitchen Manager, stated the word Slurry means the English muffin can be provided on the mechanically altered diet, but it needs to be prepared with some liquid to make it moist and soft. She further acknowledged that the above food consistencies in the above observations were not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 13 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to follow physician's orders for Resident #48 during medication administration observation and failed to accurately maintain documentation of medication administration of physician's orders for Resident #107. The findings included: Review of the fac policy, titled, Administering Medications, revised on 04/2019, documented, .the individual administering the medication checks the label THREE (3) times to verify the right .medication .before giving the medication . Review of the facility's policy, titled, Policies and Procedures - Pharmacy Services for Nursing Facilities, with a revised date of January 2018, included the following: Documentation (including electronic) 1) The individual who administers the medication dose records the administration on the resident's Medication Administration Record/electronic Medication Administration Record (MAR/eMAR) directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. 6) If a dose of regularly scheduled medication is withheld, refused, or not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed an circled. If electronic MAR is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR system. 1. Review of Resident #48's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident diagnoses included Aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking), Cerebral Infarction, Dysphagia, Gastro-Esophageal Reflux, Hemiplegia and Hemiparesis following Cerebrovascular Disease. Review of Resident #48's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0 of 15 indicating the resident had severe cognition impairment. The assessment documented under Functional Status the resident needed extensive assistance with his activities of daily living (ADLs) from the facility's staff. Review of Resident #48's physician order dated 04/05/16 documented Aspirin EC (Enteric Coated) tablet Delayed Release 325 milligrams (mg) give 1 tablet one time a day for CAD [Coronary Artery Disease]. On 03/20/23 at 9:19 AM, medication administration observation for Resident #48 performed by Staff H, Registered Nurse (RN) was conducted. Observation revealed Staff H reached a bottle of Aspirin 325 mg from the medication cart 2W-1 top drawer and poured one tablet into the medication cup. Staff H continued to pour other medications for the resident then entered the resident's room and administered the medication to the resident. On 03/21/23 at 9:15 AM, a side-by-side review of the facility's medication cart review 2West-1 was conducted with the Unit Manager (UM). The medication cart's first drawer revealed an opened bottle of Aspirin 325 mg. An inquiry was made regarding a physician order for Aspirin EC. The UM stated if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 14 of 15 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 105609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nspire Healthcare Tamarac 5901 NW 79th Avenue Tamarac, FL 33321 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the physician order says EC that the resident is supposed to get Aspirin EC. The UM stated the bottle of Aspirin 325 mg in the medication cart was not EC (enteric coated). The UM stated there was not a bottle of Aspirin EC in the medication cart. The UM was apprised that on 03/20/23 during medication administration observation for Resident #48, Staff H, RN administered plain Aspirin 325 mg and not Aspirin EC as per physician's order. A side-by-side review of Resident #48's physician order for 'Aspirin EC 325 mg give one tablet daily' was conducted with the UM. The UM stated the facility had Aspirin EC in stock. On 03/21/23 at 9:24 AM, a side-by-side review of the facility's 2-West wing medication room was conducted with the UM. The review revealed no Aspirin EC in stock. On 03/21/23 at 9:34 AM, a side-by-side review of the facility's 2-West-2 medication cart was conducted with Staff G, Licensed Practical Nurse (LPN). The medication cart had a bottle of Aspirin 325 mg. There was not a bottle of Aspirin EC 325 mg. Staff G stated she did not have Aspirin EC and that she had administered regular Aspirin, not EC to Resident #48 because that was what they had in the cart. On 03/21/23 at 9:35 AM, an interview with the Director of Nursing (DON), when asked to open the Central Supply room, the DON stated there was no Aspirin EC 325 mg in the Central Supply room. A side-by-side review of the Central Supply room was conducted with the Central Supply Coordinator. The review of the facility's 'over-the-counter stock Aspirin', located in the Central Supply room, revealed multiple bottles of Aspirin 325 mg and multiple bottles of Aspirin EC 81 mg. Observation revealed there were no Aspirin EC 325 mg bottles in the room. During the interview, the Central Supply Coordinator stated she orders Aspirin EC 81 mg and Aspirin 325 mg bottles every week. The Central Supply Coordinator stated that she had not been told they need Aspirin EC 325 mg, so had not ordered Aspirin EC 325 mg in the last 8 months since she had been on the job. 2. During a medication pass observation conducted on 03/20/23 at 9:09 AM with Staff J Licensed Practical Nurse (LPN) for Resident #107, Staff J pulled 12 different medications for the resident including: Docusate Sodium 100 milligram (mg) and Polyethylene Glycol 17gm. The resident had refused Docusate Sodium and the Polyethylene Glycol. Record review of the Medication Administration Record for Resident #107 revealed on 03/20/23 the resident had received Docusate Sodium 100mg and Polyethylene Glycol 3350 Oral Powder 17gm. During an interview conducted on 03/20/23 at 11:46 PM with Staff J, when asked how she charts a medication that has been refused by a resident, she stated it is supposed to be documented on the MAR when she is charting. She stated there is a code to put on the MAR that the resident refused the medication. When Staff J was shown the documentation on the MAR for the Docusate Sodium 100mg and the Polyethylene Glycol 3350 Oral Powder 17gm for Resident #107, she acknowledged that she had documented the medications as given. She then stated but I can go back and change the information at any time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105609 If continuation sheet Page 15 of 15