Health inspection·February 9, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a clean, sanitary, homelike environment for the residents in the facility. The findings included: 1. During the initial tour of the facility conducted on 02/06/23 at 9:30 AM, it was observed that the resident in room [ROOM NUMBER]B had a broken, jagged stone windowsill. This jagged edge could potentially cause injury to a resident, staff member, or visitor due to the uneven and jagged surface. Photographic evidence obtained. 2. During the initial tour of the facility conducted on 02/06/23 at 9:45 AM, it was observed that the resident in room [ROOM NUMBER]A had a nightstand with chipped, missing and broken façade visible on the front leg of the nightstand. Photographic evidence obtained. 3. During the initial tour of the facility conducted on 02/06/23 at 9:45 AM, it was observed by the surveyor that the resident in room [ROOM NUMBER]B had a dresser with a broken drawer. The drawer was observed to be hanging out of the dresser at an odd angle. Further observation also revealed the chair in the resident's room had two large, dark stains on the seat cushion. Photographic evidence obtained. 4. During the initial tour of the facility conducted on 02/06/23 at 10:23 AM, it was observed that the resident in room [ROOM NUMBER]B had a large, dark, point-shaped chip present in the middle of the flooring of her side of the room. Photographic evidence obtained. 5. During the initial tour of the facility conducted on 02/06/23 at 10:30 AM, it was observed that the resident in room [ROOM NUMBER]A had a large crack present in the flooring of his side of the room. Further observation also revealed a nightstand with chipped, missing and broken façade visible on the front leg of the nightstand. Photographic evidence obtained. 6. During the initial tour of the facility conducted on 02/06/23 at 10:35 AM, it was observed that the resident in room [ROOM NUMBER]B had a nightstand with chipped/missing/broken façade visible on the front leg of the nightstand. Further observation also revealed this resident's bedside rolling table had a broken and chipped top which was being held together with clear box tape. Photographic evidence obtained. 7. During the initial tour of the facility conducted on 02/06/23 at 10:45 AM, it was observed that Page 1 of 13 105679 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident in room [ROOM NUMBER] had a leaking faucet in her bathroom. Further observation of the bathroom revealed the raised toilet seat had two large rust spots and cracked, jagged and peeling paint. These rust spots and peeling paint posed a potential hazard, as these could cause a skin tear when a resident is sitting on the seat. Further observation of the resident room revealed the flooring transition (from the hallway into the resident room) was missing flooring, causing a large gap, approximately 1 inch wide. This gap posed a potential tripping hazard; it was also not possible for the staff to properly clean this area of the floor, which caused a potential for contamination. Photographic evidence obtained of these three areas of concern. 8. During the initial tour of the facility conducted on 02/06/23 at 10:50 AM, it was observed that the resident in room [ROOM NUMBER] had paint which was raised, bubbled and stained surrounding the air conditioning vent in the ceiling of entry way of the room. Photographic evidence obtained. 9. During the initial tour of the facility conducted on 02/06/23 at 12:08 PM, it was observed that the Women's Shower Room on the 200 Unit had a large area of black and slimy substance on the floor of the shower area. It appeared that this area of the shower room had not been cleaned recently. Photographic evidence obtained. 10. During the initial tour of the facility conducted on 02/06/23 at 12:10 PM, it was observed that the Men's Shower Room on the 200 Unit had 2 of 2 floor drains caked with dirt, dust, and hair along with a small area of black and slimy substance on the floor of the shower area. It appeared that these areas of the shower room had not been cleaned recently. Photographic evidence obtained. A tour of the facility was conducted on 02/09/23 at 9:50 AM with the facility's Maintenance Director, the facility's Housekeeping Director, and a Corporate Environmental Services Director-in-Training. During this tour, the above-mentioned areas of concern were shared with all of these directors. During this tour, in the Men's Shower Room on the 200 Unit, the shower had been left running by an unknown staff member and it was observed that this shower room was flooding and not properly draining due to the clogged drains. The facility's Maintenance Director stated he would conduct a full tour of the facility to identify any further areas of concern later. 105679 Page 2 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 assist a resident during dining for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADL), Resident #16. Residents Affected - Few The findings included: The facility's policy, titled, ADL: Assitance, effective July 2022, stated that resident evaluations would be conducted by nursing staff and results documented for the level of assistance needed. The information will be added to the care plan. Record review documented Resident #16 was admitted on [DATE] with diagnoses to iinclude Dementia, Respiratory Disorder, and Anemia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #16 had a Brief Interview of Mental Status (BIMS) score of 03, which is severely cognitively impaired. Section G for eating showed that Resident #16 needs total independence with one person's assistance. Review of the care plan dated 02/14/23 documented Resident #16 had a nutritional problem with a history of weight loss and electrolyte imbalance. The care plan indicated to: Observe / document as indicated: Meal Consumption, Amount of assistance needed with the meal, tolerance to diet/fluids. It further showed to provide physical assistance with bathing, dressing, nail/hair care and hygiene, eating, or other ADLs as indicated. A review of the Task/Eating under question 3, showed that Resident #16 was documented as set up only for 20 meals, and four meals were documented as one-person assistance from 02/01/23 to 02/08/23. In an observation conducted on 02/6/23 at 12:06 PM, the lunch tray was brought into Resident #16's room and placed at the bedside. The tray was observed with oven-fried chicken, mashed potatoes, spinach, fortified pudding, and 4 ounces of a mighty shake (nutritional supplements). Staff was not in the room and Resident #16 did not eat anything on her lunch tray. Continued observation at 12:34 PM did not show any staff in the room assisting Resident #16 with her meal which was 100% untouched. At 12:45 PM, the lunch tray was taken out of the room. In an observation conducted on 02/07/23 at 7:46 AM, the second meal cart arrived on the Unit. The tray was taken into the room at 8:16 AM and was set up by Staff. Closer observation showed the following: two hard-boiled eggs, wheat toast, and fortified oatmeal. In an observation conducted at 8:25 AM, Resident #16 was eating on her own with no staff in the room. Continued observation at 8:38 AM, showed that she only ate one boiled egg and her oatmeal with no staff in the room. In an interview conducted on 02/08/23 at 10:00 AM, Staff A, Certified Nursing Assistant (CNA), stated Resident #16 does not need any help with her meals and can eat on her own consistently. When asked how well she eats, she said that she eats about 75% of breakfast and she eats about 25% of her meals for lunch. In an interview conducted on 02/08/23 at 11:20 AM, Staff B, MDS coordinator, stated the resident uses the interviews with staff and observations to evaluate residents' needs with all ADLs' activities 105679 Page 3 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0677 Level of Harm - Minimal harm or potential for actual harm and to eat. She also said Resident #16 was coded as needing total dependence on one person's assistance. When asked what this meant, she said that someone had to be in the room at all times to assist Resident #16 with her meals. Staff B stated that staff need to do all the work for Resident #16 because she depends on staff for eating. Residents Affected - Few 105679 Page 4 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0687 Provide appropriate foot care. 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 provide podiatry care in a timely manner for 1 of 1 sampled resident reviewed for Podiatry Care, Resident #100. Residents Affected - Few The findings included: Review of the facility's policy, titled, Referral Services, effective 02/21, documented in part, .the Social Services Director or designee works with the interdisciplinary team to identify needs, evaluate resources and coordinate community resources to meet the needs of resident .referral services may include .Podiatry Care .assist with arranging appointments .follow up on referrals .as appropriate and document the outcome of referrals . in the resident chart . Review of Resident #100's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Essential (Primary) Hypertension, Type 2 Diabetes Mellitus, Malignant Neoplasm of Bladder, Dysphagia following Cerebral Infarction, Major Depressive Disorder, Bacteremia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Atrial Fibrillation, Congestive Heart Failure, Presence of Cardiac Pacemaker, Cardiomyopathy, Edema, Memory Deficit Following Cerebral Infarction and Other Speech and Language Deficits following Cerebral Infarction. Review of Resident #100's Minimum Data Set (MDS) quarterly assessment, dated 01/28/23, documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident has no cognition impairment. The assessment documented under Functional Status the resident needed extensive to total assistance from the staff with his activities of daily living (ADLs). Review of Resident #100's care plan, titled, documented, Diabetes Mellitus: The resident has Diabetes Mellitus as evidence by: CVA (stroke), High Cholesterol, Hypertension, Type 2 Diabetes initiated on 10/26/22. The care plan interventions included: to Inspect feet weekly - initiated on 10/26/22; Podiatry Consult as Needed - initiated on 10/26/22. Review of Resident #100's physician order, dated 10/26/22, documented, Ophthalmic, Auditory, Psychological, Psychiatric, Dental, Physiatry, and Podiatry services as needed. On 02/06/23 at 10:52 AM, during an interview Resident #100 stated he had an in-grown toe nail and the Podiatrist came in when he was not in the facility. The resident stated he told the nurse that he missed the Podiatrist visit and nothing have been done about it. On 02/08/23 at 10:49 AM, an interview was conducted with the facility's Social Services Director (SSD) who stated the Social Services department did not do Podiatry Care arrangements. The SSD stated that nursing arranged for Podiatry care. The SSD stated the facility had a Podiatrist that comes to the facility. On 02/08/23 at 11:47 AM, an interview was conducted with Staff D, Registered Nurse, (RN). Staff D stated Resident #100 had an X-ray of left ankle due to pain and added that the X-rays done 01/19/23 showed an old fracture to the distal tibia. Staff D added the resident was ordered a Podiatry Consult. A side by side review of Resident #100's physician's order for Podiatry Consult, dated 01/04/23 for Ingrown toenails, was conducted with Staff D. 105679 Page 5 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff D stated the Podiatry came to the facility over three (3) weeks later on 01/28/23 (Saturday) and the resident was out with his family. Staff D was asked why Resident #100 had not been rescheduled to be seen by the Podiatrist since it was missed on 01/28/23. Staff D did not have an answer and searched for nursing documentation related to missed visits. Staff D stated she did not see any documentation regarding contacting the Podiatry to see the resident again. Staff D, RN stated they will call the podiatry to come back to see the resident, but it had not done. Staff D and the DON (Director of Nursing) were asked to submit a copy of the last Podiatry care visit note. On 02/09/23 at 11:08 AM, an interview was conducted with Staff D, RN who stated the podiatrist came in on 02/08/23 to see Resident #100. Staff D stated that the podiatrist ordered treatment for a scab on the resident's left foot and did not see that the resident had an ingrown toe nail. Staff D stated the Podiatrist told her that she comes to the facility every other Friday. On 02/09/23 at 2:10 PM, the DON provided Resident #100's podiatry consult note, dated 02/08/23. The note documented .seen at bedside for .right great toe pain. Patient states foot is sensitive to touch .left lateral ankle noted superficial skin ulcer .black scab .3.1 x 3.4 x 0.1 .Toenails plates dystrophy, discolor .A/P (assessment/plan) right and left distal .ingrown excised .TAO (triple antibiotic ointment) applied .dorsal foot skin scalp - skin prep applied to continue .left lateral ankle ulcer - Diabetic - cleansed area with moist saline gauze, TAO . At the end of the survey, previous Podiatry Care note had not been provided. 105679 Page 6 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

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. Based on observations, interviews and record review, the facility failed to ensure the E-kit (emergency medications kit), kept in the locked medication room refrigerator, had not expired medications for 1 of 2 medication storage room's refrigerator reviewed on the C-wing. The findings included: Review of the facility's policy, titled, Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 2007, documented, in part, .the nursing staff, consultant pharmacist and provider pharmacy designee checks the emergency kits regularly for expiration dating of the contents. The date of expiration is noted on the outside of the kit . Review of the pharmacy E-Kit swap out record history provided by the facility's Director of Nursing documented the last E-Kit was delivered on 06/15/22 with an expiration date on 07/22. On 02/07/23 at 12:10 PM, a side by side review of the C-wing's medication room was conducted with Staff H, Licensed Practical Nurse (LPN) and Staff D, Registered Nurse (RN). The review revealed a refrigerator with a medication box under a double lock, labeled E-kit. The outside label documented multiple medications with expired dates. A side by side review of E-kit box medication box from the refrigerator was conducted with Staff H, LPN. The box contained the following expired medications and insulin pen needles: - One (1) Insulin Lispro Pen with an expiration date on 07/2022 - One (1) Lantus Insulin Pen with an expiration date on 11/2022 - One (1) Novolin N- multi dose vial Insulin with an expiration date on 07/2022 - Four (4) Promethegan 25 mg suppositories with an expiration date on 01/2023 - Five (5) Auto shield insulin pen needle with an expiration date on 11/2022 During the review, Staff D, RN, stated that it was the pharmacy responsibility to check on the E-kit medications expiration dates, not nursing. On 02/09/23 at 12:49 PM, an interview was conducted with the facility's Director of Nursing (DON). The facility's E-kit policy was reviewed during the interview. The DON stated the consultant pharmacist comes to the facility monthly and was supposed to review the E-kit. The DON stated in addition to the monthly check, the pharmacy sends new E-kits periodically to the facility to swap out. When asked if anyone on the staff was responsible to check the E-kits or if they depend on the pharmacy for this responsibility, the DON stated, 'we depend on the pharmacy'. When asked if anyone at the facility was responsible for conducting any checks of the E-kit, the DON said 'no'. When asked if she was aware of the expired E-kit identified by the surveyor during the medication storage observations, the DON stated she was aware there were expired medications found during the medication storage observations. The DON then stated she spoke to pharmacist and the pharmacist was not aware of where the breakdown was but he would look into it and let her know. 105679 Page 7 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure dental care was provided to 1 of 1 sampled resident reviewed for dental services, Resident #70. Residents Affected - Few The findings included: Review of the facility's policy, titled, Referral Services Dental, effective 02/21, documented in part, Determine / schedule the dates for the contracted dental services to be available at the center. Identified those residents/patients who need routine services that include but are not limited to: inspection of oral cavity (new admission or annual), dental cleaning .identify residents / patients that need emergency dental services including, but not limited to the following: broken or otherwise damaged teeth, any problem requiring the immediate attention of a dentist .document all interventions in the resident/patient's medical record. Review of Resident #70's clinical record documented an admission on [DATE] with no readmissions. The resident's diagnoses included Hemiplegia and Hemiparesis following Cerebrovascular Disease Affecting Left Non-Dominant Side, Cerebral Infarction, Occlusion or Stenosis of Right Vertebral Artery, Type 2 Diabetes Mellitus, Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery, Muscle Wasting and Atrophy, and Dysphagia following Cerebral Infarction. Review of Resident #70's physician orders, dated 02/20/19, documented, Ophthalmic, Auditory, Psychological, Psychiatric, Dental and Podiatry services as needed. Physician order, dated 01/09/22, documented, Regular diet Regular texture, Regular(Thin) consistency. Review of Resident #70 Minimum Data Set (MDS) annual assessment, dated 01/24/23, documented a Brief Interview of the Mental Status (BIMS) score of 9, indicating the resident has moderate cognition impairment. The assessment documented under Functional Status the resident needed extensive assistance from the staff for her activities of daily living (ADLs) including personal hygiene. Review of the assessment's section L documented no dental issues. Review of Resident #70's care plan, titled, DENTAL: The resident has a potential or actual oral/dental problem, initiated on 03/11/21, with revision date on 03/11/21, documented an intervention as: Observe / document / report to MD (Medical Doctor) PRN (as needed) s/sx (sign and symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, [not previously identified] tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. The intervention was initiated on 03/11/21; Dental Consult as needed intervention initiated on 03/11/2021, revision date on 03/11/21. Further review of Resident #70's clinical record lacked evidence of a Dental Services consultation record or dental care provided since admission. On 02/06/23 at 9:49 AM, during an interview with Resident #70, it was noted that one of her top front teeth was moving back and forth while the resident was talking. The resident had bottom missing teeth. An inquiry was made and the resident stated that she had not had her teeth checked and had 105679 Page 8 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few loose tooth for a long time. The resident added that her bottom teeth were also loose. The resident was asked if she was having trouble eating because of the loose tooth and stated she was having a hard time eating hard food like meat. This interview was conducted in English and Spanish. On 02/08/23 at 9:53 AM, an interview was conducted with Staff C, Certified Nursing Assistant (CNA) who was assigned to Resident #70. Staff C stated she was familiar with the resident's care. Staff C was asked if she noticed Resident #70's front tooth moving back and forth when she was talking. Staff C stated that on 02/06/23, she noticed the resident had a front loose tooth but did not tell the nurse. Staff C stated she will tell the Unit Manager today. On 02/08/23 at 10:01 AM, an interview was conducted with Staff E, Licensed Practical Nurse (LPN). Staff E stated that on 02/06/23, she noticed that Resident #70's front tooth was moving but thought it was her tongue. Staff E stated she would tell the Unit Manager today so the resident can be seen by the Dentist. Staff E, LPN stated a Dental group comes to the facility every 1-2 weeks and added she was not sure about the frequency. At this time, a joint interview was conducted with Resident #70 and Staff E, LPN. Staff E confirmed that Resident #70's front tooth was loose, moving back and forth during the interview. During the interview, the resident pointed to Staff E that her bottom teeth were also loose. The resident stated in Spanish there was certain hard food that she could not chew because of her loose tooth. The resident added she was waiting for her niece to work on it because she did not understand the process. On 02/08/23 at 10:16 AM, an interview was conducted with the facility's Social Services Director (SSD). The SSD stated that she was informed today (02/08/23) by the Unit Manager that Resident #70 had a loose tooth. The SSD stated the dental hygienist was in the facility last week and this current week but had not see the resident. The SSD stated the resident was placed on the dentist list to be seen. During the interview, the SSD was asked to provide Resident #70's dental care record who stated she had to check with the medical record staff who puts the records in a certain drive, which she (SSD) did not have access to it. The SSD was apprised that there was not dental care notes in the resident's clinical record. The SSD stated Resident #70 was eligible to get dental cleaning every three (3) months. A side by side review of the resident's electronic clinical record under the record, Documents tab, was conducted with the SSD. The SSD confirmed there was not one dental care visit note uploaded in the record. The SSD who stated the Long Term Care residents are seen by a dentist regardless if they have dental issues or not. The SSD stated that residents' dental cleaning is done three times a year. The SSD stated the facility's process was that she and the MDS Coordinator meet with new residents and long term care residents to assess them for the need of a dental care. The SSD stated if the resident needs dental care, their name will be added to the dental care group log. The SSD provided the list of residents the Dental Group will be provided service to. The SSD stated that dental care was a basic need and if the resident did not have money to pay for, the facility will pay it because it's a basic need. The SSD was asked when Resident #70 was seen by the dental group and stated she could not tell. The SSD added that she will contact the dental group to find out. 105679 Page 9 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0791 Level of Harm - Minimal harm or potential for actual harm During this interview with the SSD, the facility's administrator came in to the SSD office and was asked what the surveyor needed to review. The administrator was informed that Resident #70's clinical record lack documentation of dental care services provided. The administrator was informed that on 02/06/23, it was obvious and noticeable that the resident had a loose tooth, and that the staff noticed and it was not reported until today. Residents Affected - Few On 02/08/23 at 12:14 PM, a joint interview was conducted with the Medical Records Custodian (MRC) and the SSD. The MRC stated she checked Resident #70's thin charts and did not see any dental care records. The SSD confirmed the resident had not been seen by the dentist in the last 12 months. On 02/08/23 at 2:34 PM, an interview was conducted with the MDS Coordinator / LPN who stated she completed the resident's assessments by getting information from documentation in the chart, meet with the resident, and does assess / evaluate the resident. The MDS Coordinator stated she did not notice any dental issues during Resident #70's assessment and that the resident did not voice any mouth pain or issues. On 02/08/23 at 2:50 PM, during an interview, the facility's administrator stated that the Dentist came in today and saw Resident #70. The administrator added that the dentist was going to pull the loose top tooth and fit her for dentures. The administrator was asked why Resident #70 had not been seen by the dentist and stated that the Dental group told the facility the resident was not eligible for service. The administrator added that at the end of the day if there is a dental issue, like a loose tooth, they will make sure it is taking care of. The administrator stated that it is not required that the resident gets a dental cleaning every six months. On 02/09/23 at 10:58 AM, a joint interview was conducted with Resident #70 and the Unit Manager (UM). The resident stated that she was having a hard time chewing meat, bread and fruits. The UM stated the dentist came in on 02/08/23. During the interview, the resident again pointed to the UM that her bottom tooth were also loose. The UM did not know if the resident had dental coverage or not. The UM stated she was not sure if the resident was seen for dental cleaning or not. During the interview, the UM stated Resident #70 could have an infection under the loose tooth if it is not treated. The UM informed the resident that she will have her diet change to soft foods. On 02/09/23 at 11:41 AM, an interview was conducted with the facility's Business Office Manger (BOM) who stated that Resident #70 was enrolled with Liberty Dental plan through Medicaid. The BOM stated that she did not know when her dental plan was effective but that it was effective in 2022. On 02/09/23 at 1:21 PM, the facility's Director of Nursing submitted Resident #70's Dental ServicesScreening Report, dated 02/08/23. The report documented patient has upper partial very old and loose teeth (tooth #9, 23 and 26) .patient interested in extraction of the loose teeth followed up by upper denture and lower partial. On 02/09/23 at 2:21 PM, the administrator submitted Resident #70's Dental Services- Diagnosis and Recommended Treatment, dated 05/25/21, documented patient presents for screening .tooth #9 and #26 have (class III) mobility. Patient has upper partial that does not fit due to several missing teeth. Patient interested in extractions of #9 and #26 and upper and lower partials. Need Medical Clearance. 105679 Page 10 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, and interviews, the facility failed to dispose of refuse in a sanitary and timely manner to prevent overflowing of the debris. Residents Affected - Few The findings included: In a tour conducted on 02/06/23 at 9:40 AM, in the main dumpster area with the facility's Registered Dietitian (RD) and the Food Service Director (FSD), the following were noted a large metal container was filled with garbage bags of all sizes that was overflowing. The metal container had no lid and various types of debris were noted around the container on the ground. In this observation, the facility's Maintenance Director stated the compactor had been broken for two weeks and was waiting for a replacement. He further stated the metal container is used as a dumpster until they get the new compactor and that it gets picked up every two days. An interview was conducted on 02/06/23 at 1:50 PM with the facility's Administrator who stated she was told of the findings this morning and said the metal garbage container would get picked up daily. In an interview conducted on 02/09/23 at 9:42 AM with Maintenance Director, he stated, 'you should call the city regarding the pick-up of the dumpster. It is their responsibly, not the facility.' He further stated' 'if the state came in on a weekday, it would be all cleaned, but since they came in on a Monday, it was not.' 105679 Page 11 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to keep the laundry room in a safe, clean, operating condition, during tour of the laundry room. Residents Affected - Few The findings included: A tour of the laundry area was conducted on 02/08/23 at 3:30 PM with the facility's Housekeeping Director and the corporate Environmental Services Director-in-Training. The following areas of concern were observed, and photographic evidence was obtained: 1. In the dirty linen sorting area and in the washing machine room, it was noted there were several blue isolation gowns hanging on the walls on hooks. 2. Initial observation of the washing machines revealed that the first washing machine had two tubes which were rusted off. The Housekeeping Director stated this machine was out-of-service and had been disconnected from power so the staff could not accidentally turn it on. The surveyor observed that there was laundry present in this washing machine (visible from the door). The Housekeeping Director and the corporate Environmental Services Director-in-Training stated a housekeeping staff member must have put the laundry in the washer recently. Neither the Housekeepiing Director or the corporate Environmental Service Director-in-Traing could say how long the laundry had been in the washing machine nor why it had not been removed due to the machine being out-of-service. 3. Observation of the second washing machine revealed this machine had 2 external filters, one of which was laden with dust and dirt, one of which looked as if it had been cleaned more recently. It was noted by the surveyor that there was a sign directly under each of the filters which stated, Clean filter daily. Neither the Housekeeping Director nor the corporate Environmental Services Director-in-Training were able to tell the surveyor when the filters had been cleaned last. 4. Initial assessment of the dryers revealed the first dryer had a gasket which was torn and jagged, causing a surface which was unable to be kept clean. This dryer also had a drum which appeared to be rusted and burned and had unidentified melted substances around the entire surface. The Housekeeping Director stated this dryer was in the process of being serviced and that the staff had been instructed to not use it unless necessary. He further stated a component of the drum was broken and it would only spin one way which caused the drum to become burned and have the substances melted to it. 5. Observation of the second dryer revealed this dryer's drum contained unidentified melted substances around the entire surface as well. The facility's Administrator provided copies of the work orders for the first washing machine and first dryer, both work orders were dated 02/01/23. Photographic evidence obtained. The Administrator stated she did not know how long these machines had been out-of-service. An interview was conducted on 02/09/23 at 9:17 AM with the facility's Maintenance Director who stated the first washing machine had been down for approximately four weeks. When asked why the work order was dated 02/01/23, he stated the original email with the original date was lost, and what was provided to the surveyor was a new email that had been sent to the facility and that was why it contained a new date. He stated the washing machine is broken because the computer was damaged due to the chemicals leaking from the lines which had rusted off. He said the leaking, rusted lines had also 105679 Page 12 of 13 105679 02/09/2023 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few damaged wires inside the washing machine's door. He further stated the door wires had already been replaced, the chemical lines were going to be replaced, and that the facility was waiting on a new computer to be delivered for the washing machine. The Maintenance Director then stated he told the Housekeeping Director that the surveyors would be touring the laundry on Wednesday and that they should clean up the laundry room early in the week. The Maintenance Director became upset during this interview and stated the tour of the laundry room should not have happened on 02/08/23 without him. The surveyor explained that he was requested but the Administrator did not call him. The Maintenance Director then stated the Housekeeping Director did not know the proper responses and that he was responsible (referring to himself) for the maintenance of the laundry room. In an interview with a staff person in the laundry room at 9:43 AM, he stated he is not responsible for the care and maintenance of the laundry. A secondary tour of the laundry facility was conducted on 02/09/23 at 9:30 AM with the Maintenance Director and another surveyor. The following additional areas of concern were observed, and photographic evidence was obtained: 6. The Maintenance Director stated and it was observed that the dryer drums had been cleaned, but the drum in the first dryer continued to have a rusted and burned appearance. Further observation of the lint area below the first dryer revealed mounds of dark, burned unidentified brown substance. When the surveyors showed this to the Maintenance Director, he became upset and stated he would have to pull the whole drum out to service this area of concern. The Maintenance Director further stated the first dryer is not broken and he did not know why the Housekeeping Director would tell the surveyors that it was broken. When the surveyor asked why there was a work order for the dryer if it was not broken, the Maintenance Director did not respond. 7. In the washing machine room, it was observed that the drainage area behind both washing machines was caked with an unidentified substance which was peeling off. Further observation of the drain behind the second washing machine revealed a build-up of debris, including dirty gloves, packages, caps, coins, and papers. This drain area also had a back-up of milky water. The Maintenance Director stated he had cleaned this area one week ago. He further stated that it is not his responsibility to clean the laundry room but it is the responsibility of the housekeeping staff. When asked why the laundry room is in this state if it was cleaned one week ago, the Maintenance Director became upset and stated it is because the housekeeping staff is not keeping up with it. 105679 Page 13 of 13