Health inspection·October 20, 2022

F 0583 Keep residents' personal and medical records private and confidential. 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 privacy of confidential information by leaving unlocked unattended computer screens with residents' information visible for two out of three medication carts observed. The facility has a total of six medication carts. This deficient practice has the potential to affect all 140 residents in the facility at the time of this survey. Residents Affected - Few The findings included: 1) During a medication administration observation conducted with Staff I, a Registered Nurse (RN ) on 10/18/22 at 5:17 PM, Staff I left the computer on top of the medication cart on (logged into the electronic charting system) and unattended, facing out into the main hallway while she entered room [ROOM NUMBER] to administer medications to a resident. 2) During a tour of the facility conducted on 10/19/22 at 5:03 PM, an observation was made of a computer on top of a medication cart that was left on (logged into the electronic charting system) and unattended, facing out into the main hallway of the 2nd floor near room [ROOM NUMBER]. On 10/19/2022 at approximately 5:10 PM Staff J, RN was notified by the surveyor that the computer had been left on. Staff J did not verbally respond but did lock the screen. 3) During a medication administration observation conducted with Staff J on 10/19/22 at 5:20 PM, the surveyor observed Staff J leave the computer on top of the medication cart on (logged into the electronic charting system) and unattended, facing out into the main hallway when she entered room [ROOM NUMBER] to administer medications to a resident. On 10/19/2022 at approximately 6:30 PM the Director of Nursing was informed of the concerns. Page 1 of 22 106021 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

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 observation, interview, and record review the facility failed to address services related to Activities of Daily Living (ADL) related to the grooming of a resident's fingernails; as evidenced by failure to ensure the fingernails were trimmed and cleaned for 1 (Resident # 137) of 1 resident reviewed. Residents Affected - Few The findings included: In an observation conducted on 10/17/22 at 9:30 AM, Resident #137 was noted in bed. Closer observation showed long, thick, sharp-edged, dirty fingernails with some dark, black matter noted at the rim of the nail base/bed. In this observation, Resident #137 was asked if she wanted her fingernails trimmed and she said yes. (Photographic evidence obtained). A chart review showed that Resident #137 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Dementia and Anxiety. The Minimum Data Set (MDS) dated [DATE] showed that Resident #137 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicate the resident is cognitively intact. The Care Plan dated 10/17/22 showed that Resident #137 is at risk for deterioration in ADL function and medical stability secondary generalized weakness, and anxiety. It further showed that Resident #137 will maintain current level of ADL functional status according to her abilities through the review date. Check nail length and clean and/or trim on bath day as necessary and report any changes to the nurse. In an observation conducted on 10/18/22 at 8:10 AM Resident #137 was noted in bed. Closer observation showed long, thick, sharp-edged, dirty fingernails with some dark, black matter noted at the rim of the nail base/bed. In an interview conducted on 10/19/22 at 9:00 AM, Staff C, a Certified Nursing Assistant, stated that the 3:00 PM to 11:00 PM shift usually cut and trim the resident's fingernails and sometimes activities will do it. Staff C further stated that she looks at resident's fingernails daily and if she feels that they need to be trimmed or cut she will go ahead and do it. Staff C was then asked why she did not cut and trim Resident #137 fingernails. Staff C stated that Resident #137 is fidgety about her fingernails and does not like them cut. During this interview, Staff C was asked to accompany the surveyor to Resident #137's room. Resident #137 was asked if she would like to have her fingernails cut and trimmed by Staff C and she responded yes. A review of the facility's policy titled Fingernails, Care of revised in February 2022 showed that following: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding. During an interview conducted on 10/20/22 at 11:00 AM, the facility's Director of Nursing was informed of the findings. 106021 Page 2 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to perform appropriate nutrition monitoring on a resident who was admitted with a stage two pressure ulcer and poor oral intake and failed to provide the appropriate assistance during dining for 1 of 8 sampled residents reviewed for nutritional risk (Residents #490). Residents Affected - Few The findings included: A review of the facility's Nutritional Assessment, revised on 1/18/2022, documented that the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutritional. A chart review showed that resident #490 was admitted to the facility on [DATE] with diagnoses of anorexia, dysphagia, and dementia. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #490 has a Brief Interview of Mental Status (BIMS) score of 04 out of 15 , which indicate the resident has severe cognitive impairment. Section G of the MDS showed that Resident #490 needed extensive assistance with one person assist for eating. In an observation conducted on 10/17/22 at 12:28 PM, Resident #490 received her lunch tray in the room and ate her lunch meal without assistance from staff. Continued observation showed staff assisting Resident #490's roommate with lunch meal. At 12:50 PM, Resident #490's lunch tray was taken out of the room and was noted to be 95% untouched. In an observation conducted on 10/18/22 at 7:40 AM, Resident #490 received her breakfast tray in the room and ate her meal without assistance from staff. She ate 100% of her oatmeal and a few spoons of her eggs. At 8:00 AM, staff came in the room and encouraged Resident #490 to finish her breakfast tray. At 8:07 AM the tray was taken out of the room by staff. The weights documented in the electronic chart showed the following weights recorded for Resident #490: admission weight on 09/05/22 at 124 pounds, on 09/13/22 at 122 pounds, on 09/19/22 at 119 pounds and on 10/07/22 at 117 pounds. The Nutrition Full Assessment conducted on 09/06/22 which was 4 days after Resident #490's admission showed that Resident #490 was admitted with a stage 2 pressure ulcer to the sacrum, recent hospitalization, and was placed under isolation for COVID-19 infection. In this note, the facility's Registered Dietitian assessed her caloric daily needs at 1680 calories and her protein daily needs between 67 grams to 78 grams a day. A review of the facility's Menu Nutritional Analysis revealed that the Week 1 menu cycle provides a weekly average of 84.6 grams of protein, Week 2 provides a weekly average of 80.9 grams of protein, and Week 3 provides a weekly average of 69.6 grams of protein. Week 4 provides a weekly average of 89.3 grams of protein. The percentage intake of meals completed by the Certified Nursing Assistant showed that from 09/20/22 to 09/30/22, Resident #490 consumed 10 meals at 25%, 12 meals at 50%, 6 meals at 75%, and only 3 meals at 100%. This showed that Resident #490 ate an average of 50% intake daily of her meals. 106021 Page 3 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Compared to the facility's weekly average of protein, Resident #490 ate an average of 41 grams of protein daily. Resident #490 consumed 52% to 61% of her estimated protein needs that the Clinical Dietitian recommended in the Nutrition Full Assessment. The Malnutrition Risk Assessment completed on 09/06/22 by the facility's Clinician Dietitian, showed that Resident #490 was at risk for malnutrition upon admission. The Nutrition/Dietary Note completed on 09/13/22, 11 days after Resident #490's admission, showed that she was at high risk for weight loss and decline in nutritional parameters due to COVID-19 infection. It further showed that Resident #490 was seen by the Wound Care doctor and that she had nutritional support in place for wound healing. In this note, it was recommended to start Resident #490 on a bottle of Glucerna® (nutritional supplement) once a day which was created on 09/06/22. The Clinical Dietitian noted that Resident #490 was with acute kidney failure and that she would monitor and intervene as needed. The Nutrition/Dietary Note completed on 09/20/22, 18 days after Resident #490's admission, showed that she continued with poor PO (oral/by mouth) intake and that the Wound Care Doctor saw her for the s`stage 2 sacrum wound. On this note, the Clinical Dietitian recommended Megace (appetite stimulant) but did not increase the Glucerna® to more times a day and did not recommend any extra protein for wound healing. The Nutrition/Dietary Note completed on 09/21/22, 19 days after Resident #490's admission, showed that a Prealbumin lab (the lab that shows visceral protein status) was taken. A follow-up Nutrition note dated 09/26/22 showed that Megace (for appetite stimulant) was started on 09/26/22, )24 days after Resident #490's admission) and Pro-Stat Liquid (protein supplement for wound healing), started on 09/26/22 (24 days after Resident #490's admission). A review of the Medication Administration Record (MAR) intake for the Glucerna®once a day showed that from 09/06/22 to 09/30/22, Resident #490 consumed the following: 3 cans at 75% intake, 1 can at 50% intake, and 10 cans at 100% intake. This showed that the Resident drank an average of 64% of the bottle daily. A continued review of the MAR for October 2022 showed that the Clinical Dietitian recommended increasing the Glucerna® supplement to twice a day which was only done on 10/09/22, (37 days after admission). The Care plan dated 09/15/22 showed that Resident #490 is at nutritional risk with 7#/5.6% significant weight loss x 30 days and poor PO intake. It further showed to monitor intake at all meals, offer alternate choices as needed, and alert the Doctor and Dietitian to any decline in intake. The Wound Care note dated 09/06/22 showed that Resident #490 had a Sacrum stage 2 pressure injury that measures 0.8 x 0.8 x 0.2 centimeters (cm). It further revealed that the wound care doctor noted a dietary recommendation regarding high protein intake. The Wound Care note dated 09/13/22 showed that Resident #490 had a sacrum stage 2 pressure injury that measures 1.8 x 1.8 x 0.2 cm and a dietary recommendation regarding high protein intake. In an interview conducted on 10/19/22 at 10:33 AM with the facility's Clinical Dietitian, she stated that she did not provide extra protein to Resident #490 because she was admitted with acute kidney failure. When asked why she did not increase the Glucerna® supplements to more than once a day until a month later, she said, I ordered Prealbumin level and wanted to monitor Resident #490's 106021 Page 4 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few visceral protein status before I increased the Glucerna® supplement. She further stated that not all residents admitted with a stage 2 pressure ulcer are provided with an extra protein supplement. As for the nutritional interventions, she recommended psychotropic medication and a psych consultation. When asked how she addressed the wound care doctor's notes regarding a high-protein diet, she did not answer. Surveyor pointed out that Resident #490 was admitted with a stage 2 pressure ulcer and was assessed by her with malnutrition. Surveyor expressed concern with the timing of the nutritional interventions. In an interview conducted on 10/20/22 at 8:20 AM with Staff D, License Practical Nurse, and Staff E, a Registered Nurse, they stated that the wound care rounds are conducted weekly with the Wound Care doctor. When asked about the recommendations for a high protein diet, they said that it is needed to help restore tissues, especially when a resident has a pressure ulcer. When the Wound Care doctor makes the recommendations for a high-protein diet, it is transmitted verbally to the facility's Dietitian in the morning meetings. The facility's Dietitian oversees ensuring that a high-protein diet is provided to the Resident. When asked about Resident #490, they said that the PO intake of meals is monitored to ensure that the Resident eats all the protein provided with the daily meals. If they do not, then a protein supplement is offered to help with wound healing. In an interview conducted on 10/19/22 at 1:00 PM, with the Corporate Dietitian, she acknowledged all findings. 106021 Page 5 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

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 records reviewed,observations and interviews, the facility failed to assure that enteral nutrition has been followed by the practitioner's order for 1 (Resident #50) of 2 sampled residents reviewed for tube feeding. There were 19 residents receiving tube feeding residing in the facility at the time of this survey. The findings included: A chart review showed that Resident #50 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, Dementia, and Dysphagia. A review of Resident #50's physician orders showed an order for tube feeding Jevity 1.5 (formulary type) at 65 milliliters (ml) an hour times 20 hours to be off at 8:00 AM and on at 12:00 PM. In an observation conducted on 10/17/22 at 9:15 AM, Resident #50 was noted in bed. Closer observation showed a tube feeding bottle with Jevity 1.5 (formulary type) that was started at 5:02 AM on 10/17/22. Closer observation showed that the tube feeding was at the 1500 milliliters (ml) mark out of a 1500 ml capacity bottle. No tube feeding formulary was infusing at the time of observation. According to the practitioner's tube feeding order, the tube feeding should have been at the 1240 ml mark out of the 1500 ml capacity bottle. In an observation conducted on 10/17/22 at 11:00 AM, Resident #50 was noted in bed. Closer observation showed a tube feeding bottle with Jevity 1.5 (formulary type) that was started at 5:02 AM on 10/17/22. Closer observation showed that the tube feeding was at the 1500 milliliters (ml) mark out of a 1500 ml capacity bottle. No tube feeding formulary was infusing at the time of observation. In an observation conducted on 10/17/22 at 12:30 PM, Resident #50 was noted in bed. Closer observation showed a tube feeding bottle with Jevity 1.5 (formulary type) that was started at 5:02 AM on 10/17/22. Closer observation showed that the tube feeding was at the 1500 milliliters (ml) mark out of a 1500 ml capacity bottle. No tube feeding formulary was infusing at the time of observation. In an observation conducted on 10/17/22 at 12:50 PM, the tube feeding was just started with Jevity 1.5 at 65 ml an hour. In an observation conducted on 10/18/22 at 7:40 AM, Resident #50 was noted in bed. Closer observation showed a tube feeding bottle with Jevity 1.5 (formulary type) that was started at 5:55 AM on 10/18/22. Closer observation showed that the tube feeding was at the 1500 milliliters (ml) mark out of a 1500 ml capacity bottle. No tube feeding formulary was infusing at the time of observation. According to the Practitioner's tube feeding order, the tube feeding should have been around 1350-1370 ml mark out of the 1500 ml capacity bottle. In an observation conducted on 10/19/22 at 7:40 AM, Resident #50 was noted in bed. Closer observation showed a tube feeding bottle with Jevity 1.5 (formulary type) that was started at 6:00 AM on 10/19/22. Closer observation showed that the tube feeding was at the 1500 milliliters (ml) mark out of a 1500 ml capacity bottle. No tube feeding formulary was infusing at the time of observation. According to the Practitioner's tube feeding order, the tube feeding should have been around 1350-1370 ml mark out of the 1500 ml capacity bottle. 106021 Page 6 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan dated 08/29/22 showed that Resident #50 is at risk for altered nutritional status related to tube feeding, and she is totally dependent on staff. It further showed that Resident #50 is on enteral feeding for alternate means of nutrition related to dysphagia and to administer enteral feeding as ordered. A nutrition progress note dated 08/25/22 revealed that Resident #50's tube feeding was increased two months ago due to weight loss. She remains with nothing by mouth an Indefinitely dependent on her enteral feeding tube as her primary source of nutrition and hydration. She receives tube feeding Jevity 1.5 ml an hour for 20 hours, providing 1950 calories, 83 grams of protein, and 1788 ml of fluids a day. An interview with Staff A, License Practical Nurse, on 10/18/22 at 7:53 AM stated that the night shift changed the tube feeding bottle overnight. Resident #50's tube feeding is usually stopped around 8:00 AM for 4 hours to provide a bath and morning care, and it later resumes at around 12:00 PM. He further reported that Resident #50 is tolerating her tube feeding well. In an interview conducted on 10/19/22 at 1:00 PM, with the Corporate Dietitian, she acknowledged all findings. 106021 Page 7 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews the facility failed to perform adequate tracheostomy care for one (Resident #78) out of one resident residing in the facility with tracheostomy. Residents Affected - Few The findings included: Review of the facility policy titled Tracheostomy Care, revision date January 2022, revealed the following: In the Procedure Guidelines, which spells out each step for the staff to follow during tracheostomy care, this policy specifies the staff is supposed to wash their hands and don (put on) non-sterile exam gloves and remove oxygen tubing from on top of the tracheostomy and remove the old tracheostomy dressings and the disposable inner cannula (the tube that the resident breaths through). The staff is then supposed to remove the non-sterile exam gloves, wash hands, and then open the tracheostomy cleaning kit. While maintaining a sterile field, the staff should set up the supplies which are included in the kit (hydrogen peroxide, normal saline, gauze pads) along with a new tracheostomy inner cannula, new neck ties (a fabric device used to keep the tracheostomy in proper placement in the resident's neck), and a new fenestrated gauze pad (a special gauze pad which is split down the middle to fit around the outside of the tracheostomy stoma to help keep the area clean). After the supplies are set up, the staff is then supposed to don sterile gloves. Using these sterile gloves, the staff should place the new inner cannula into the tracheostomy. After this is in place, the staff should remove the sterile gloves and don non-sterile exam gloves to clean, dry, and disinfect the stoma. After this is complete, the staff should replace the neck ties, place the new fenestrated gauze pad around the insertion site, and replace the oxygen tubing onto the tracheostomy. The staff is then done with tracheostomy care and can remove their gloves and wash their hands. Records reviewed revealed Resident #78 was admitted to the facility on [DATE]. Resident #78 medical history include but not limited to significant brain damage caused by lack of oxygen, seizures, and respiratory failure. An Annual Minimum Data Set was completed on 09/07/22. The Brief Interview of Mental Status score was 99, which indicates Resident #78 had severe cognitive dysfunction. Under Section O (for Special Treatments) it is documented that Resident #78 required tracheostomy care, suctioning, and oxygen. Review of Resident #78's Care Plans, revealed care plans in place regarding Resident #78 having a tracheostomy due to chronic respiratory failure and impaired breathing mechanics. Review of Resident #78's physician orders, revealed orders in place for tracheostomy care to be done each shift and as needed and for suctioning of the tracheostomy to be done as needed for phlegm. During an observation and interview tracheostomy care was conducted on 10/19/22 at 2:23 PM. The staff involved were Staff F, Registered Nurse (RN) as the lead and Staff G, RN assisting; there was also a Certified Nursing Assistant (CNA) in attendance. The supplies were gathered and were on a clean surface prior to the surveyor entering Resident #78's room-there were 2 sterile tracheostomy cleaning kits which each included sterile gloves, sterile normal saline, sterile gauze, sterile Q-tips, hydrogen peroxide, and fenestrated gauze pads; there was also a new tracheostomy inner cannula, a new tracheostomy mask (which delivers oxygen into the tracheostomy), and new neck ties. Staff F and Staff 106021 Page 8 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few G washed their hands and donned face shields and gloves. The CNA assisted the nurses in donning the isolation gowns. Staff G put a pulse oximeter on Resident #78's finger prior to starting the tracheostomy care to monitor his oxygen status and heart rate. Staff F opened the sterile tracheostomy cleaning kits first and donned her sterile gloves. Staff F then set up the supplies-she opened the sterile packets of hydrogen peroxide and the bottle of sterile normal saline and poured both of these solutions into the sterile tray. Staff F also set up the gauzes and Q-tips for cleaning, drying, and disinfecting the tracheostomy stoma. Staff G removed Resident #78's old tracheostomy inner cannula from the tracheostomy with non-sterile gloves. Staff G also removed the fenestrated gauze pad from under the tracheostomy. Staff F then used sterile Q-tips with the peroxide/saline solution to clean around the tip of the tracheostomy. Staff F then used sterile gauze with the peroxide/saline solution to clean the skin around the tracheostomy. Staff F then used dry sterile gauze to try the tip of the tracheostomy and the skin around the tracheostomy. Staff G then removed the original neck ties and assisted Staff F in putting the new neck ties in place. Staff F and Staff G then placed the new drain sponge around the tracheostomy stoma. Staff F then placed the new tracheostomy inner cannula into the tracheostomy. Staff G then assisted Staff F in placing the new tracheostomy mask onto the tracheostomy. Staff F and Staff G then removed their gloves, face shields, and gowns and washed their hands. It was noted by the surveyor that Staff F wore the same original sterile gloves throughout this whole procedure, despite the facility's policy stating that the sterile gloves should be worn only for the step of placing the new inner cannula into the tracheostomy. It was also noted that this step was done at the end of the procedure, despite the facility's policy stating it should be one of the first steps to be done. 106021 Page 9 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure the medication error rate is less than 5%. The facility failed to administer the ordered medication Oxycodone/Acetaminophen 5/325 mg for 81 out of 682 opportunities, (11.88 % error rate) for 1 of 8 sampled residents for medication administration review (Resident #59). Residents Affected - Few The findings included: Observation of medication administration on 10/19/22 07:46 AM for Resident #59 conducted by Registered Nurse (RN), Staff F revealed the following administered medications by mouth: Duloxetine 30 mg (milligrams), aspirin 81 mg EC (Enteric Coated), Oxycodone/APAP 5-325 mg, folic acid 800 mcg (micrograms), Metoprolol tart 25 mg, multivitamin with minerals, vitamin D 25 mcg, ferrous sulfate 325 mg, vitamin C 500 mg, docusate sodium 100 mg, Memantine HCL 10 mg. Record review of Resident #59's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Covid-19, Persistent Mood (Affective) Disorder, Obesity, Other Chronic Pain, Alzheimer's Disease, Unspecified Osteoarthritis, Contracture of Left Hand, Other Hereditary and Idiopathic Neuropathies, Dementia, Anxiety Disorder, Pain Unspecified, Major Depressive Disorder. Review of the Prospective Payment System (PPS) 5 Day Minimum Data Set (MDS) dated [DATE], Section C revealed for cognitive status indicate that Resident #59 had a Brief Interview for Mental Status score of 4 out of 15, which indicated that she has severe cognitive impact. Review of Section G for functional status revealed for bed mobility Resident # 59 had a self-performance of extensive assistance with support of one-person physical assist, for dressing, toilet use, and personal hygiene all had a self-performance of total dependence with support of one-person physical assist. Review of Section J for health conditions revealed Resident #59 was receiving a scheduled pain medication regimen, a pain assessment interview was conducted that included asking the resident Have you had pain or hurting at any time in the last 5 days? the reply was no. Review of the Physician's Orders revealed that Resident #59 had an order dated 07/29/19 for Acetaminophen 325 mg, give 2 tablets orally every 6 hours as needed for pain. Review of the Physician's Orders revealed that Resident #59 had an order dated 08/12/21 for Alendronate 70 mg, give 1 tablet orally one time a day every Tuesday related to age-related osteoporosis without current pathological fracture. Review of the Physician's Orders revealed that Resident #59 had an order dated 11/08/21 for Clonazepam 0.5 mg, give ½ tablet orally tow times a day related to anxiety disorder. Review of the Physician's Orders revealed that Resident #59 had an order dated 08/26/21 for Duloxetine 30 mg, give 1 capsule orally one time a day related to major depressive disorder. Review of the Physician's Orders revealed that Resident #59 had an order dated 09/27/21 for Gabapentin 300 mg, give 1 capsule orally every 8 hours related to other chronic pain. Review of the Physician's Orders revealed that Resident #59 had an order dated 12/03/21 for 106021 Page 10 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Lidocaine Pain Relief 4% Patch, apply to left knee topically one time a day related to other chronic pain. Level of Harm - Minimal harm or potential for actual harm Review of the Physician's Orders revealed that Resident #59 had an order dated 12/03/21 for Lidocaine Pain Relief 4% Patch, apply to remove topically at bedtime for pain. Residents Affected - Few Review of the Physician's Orders revealed that Resident #59 had an order dated 06/03/21 for Mirtazapine 15 mg, give 1 tablet orally at bedtime related to insomnia. Review of the Physician's Orders revealed that Resident #59 had an order dated 10/27/21 to Monitor pain scale with pain rating scale every shift (1-2=mild; 3-5=moderate; 6-8=severe; 9-10=worst). Review of the Physician's Orders revealed that Resident #59 had an order dated 12/06/21 for Oxycodone-Acetaminophen 5-325 mg, give 1 tablet by mouth every 4 hours for pain related to other chronic pain. Review of the Care Plan for Resident #59 with an initiated date of 12/07/21 and a revision date of 10/03/22 documented focus indicated the resident is at risk for pain related to diagnoses: Hypertensive Retinopathy, Peripheral Vascular Disease (PVD), Low Back Pain, Osteoarthritis, Osteoporosis, Anemia, Left Hand Contracture, GERD, and Idiopathy Neuropathy. Goal was the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The interventions included: Give medications as ordered. Observe, and document the frequency and intensity of the pain symptoms. Use the resident's verbal reports and staff's clinical judgment for this assessment. Follow a standardized assessment tool. Observe/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Observe/document the effectiveness or ineffectiveness of medication and notify medical doctor (MD) as needed. Provide non-pharmacological interventions such as repositioning, noise and light reduction. Review of the October Medication Administration Record (MAR) for Resident #59, revealed the resident was not administered (excluding when resident was sleeping or had refused medication) her routinely scheduled Oxycodone-Acetaminophen 5-325 mg 24 times out of 105 opportunities. The dates/times and reason (if any) the routinely scheduled Oxycodone-Acetaminophen 5-325 mg was not given is as follows: On 10/05/22 at 8:00 AM and 12:00 PM no documentation (left blank). On 10/09/22 at 12:00 PM no documentation (left blank). On 10/11/22 at 4:00 PM and 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff I - Registered Nurse. On 10/12/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff K - Registered Nurse (agency). On 12/13/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff K - Registered Nurse (agency). On 10/13/22 at 4:00 PM and 8:00 PM no documentation (left blank). 106021 Page 11 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/14/22 at 8:00 AM documentation of 4, indicating Outside of Parameter documented by Staff EE Nurse. On 10/14/22 at 4:00 PM and 8:00 PM no documentation (left blank). On 10/15/22 at 8:00 AM and 12:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff L - Registered Nurse. On 10/16/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff M Licensed Practical Nurse (agency). On 10/16/22 at 8:00 AM and 12:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff L - Registered Nurse. On 10/16/22 at 4:00 PM and 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff M Licensed Practical Nurse (agency). On 10/17/22 at 12:00 AM and 4:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff M Licensed Practical Nurse (agency). Review of the October Medication Administration Record (MAR) for Resident #59, revealed the resident was monitored for pain with a rating scale every shift (excluding when the resident had a 0-pain score) was as follows: On 10/05/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 4, indicating moderate pain as documented by Staff CC - Licensed Practical Nurse. On 10/15/22 the evening shift (3:00 PM - 11:00 PM) pain level was recorded as a 4, indicating moderate pain as documented by Staff M Licensed Practical Nurse (agency). On 10/15/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 3, indicating moderate pain as documented by Staff M Licensed Practical Nurse (agency). On 10/16/22 the evening shift (3:00 PM - 11:00 PM) pain level was recorded as a 3, indicating moderate pain as documented by Staff M Licensed Practical Nurse (agency). On 10/18/22 the day shift (7:00 AM - 3:00 PM) pain level was recorded as 1, indicating mild pain as documented by Staff F Registered Nurse. Review of the October Medication Administration Notes for Resident #59 included the following: On 10/11/2022 at 11:47 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending script entered by Staff I Registered Nurse. On 10/11/2022 at 11:48 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending script entered by Staff I Registered Nurse. On 10/12/2022 at 1:10 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG no given pending new prescription in pharmacy entered by Staff K Registered Nurse (agency). 106021 Page 12 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Level of Harm - Minimal harm or potential for actual harm On 10/12/2022 at 4:21 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pharmacy was call; patient need a new prescription for this medication entered by Staff K Registered Nurse (agency). On 10/13/2022 at 12:53 AM Medication Administration Residents Affected - Few Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pt. (patient) need new prescription on pharmacy entered by Staff K Registered Nurse (agency). On 10/13/2022 at 4:36 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG New prescription id needed for this medication entered by Staff K Registered Nurse (agency). On 10/15/2022 at 11:37 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG no given, pending pharmacy pick up entered by Staff L Registered Nurse. On 10/15/2022 at 1:50 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending pharmacy pick up entered by Staff L Registered Nurse. On 10/15/2022 at 11:11 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication unavailable contact pharmacy alerted supervisor on duty entered by Staff M - Licensed Practical Nurse (agency). On 10/16/2022 at 3:46 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication unavailable f/u with charge nurse aware entered by Staff M - Licensed Practical Nurse (agency). On 10/16/2022 1:09 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending pharmacy pick up entered by Staff L Registered Nurse. On 10/16/2022 1:10 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending pharmacy pickup entered by Staff L Registered Nurse. On 10/16/2022 at 8:28 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG alerted unit nurse day before f/u today pharmacy sending with new script night run entered by Staff M Licensed Practical Nurse (agency). On 10/16/2022 at 8:30 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG f/u (follow up) with before progress notes check nurse charting entered by Staff M - Licensed Practical Nurse (agency). On 10/17/2022 at 2:18 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 106021 Page 13 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MG medication unavailable contact pharmacy alert unit supervisor coming on board alerted last shift entered by Staff M - Licensed Practical Nurse (agency). On 10/17/2022 at 5:19 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication on order, alerted oncoming nurse to f/u (follow up) entered by Staff M - Licensed Practical Nurse (agency). Review of the September Medication Administration Record (MAR) for Resident #59, revealed the resident was not administered (excluding when resident was sleeping or had refused medication) her routinely scheduled Oxycodone-Acetaminophen 5-325 mg 8 times out of 180 opportunities. The dates/times and reason (if any) the routinely scheduled Oxycodone-Acetaminophen 5-325 mg was not given is as follows: On 09/01/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff N Licensed Practical Nurse (agency). On 09/01/22 at 4:00 PM and 8:00 PM no documentation (left blank). On 09/02/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff O Registered Nurse (agency). On 09/13/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff K Registered Nurse (agency). Review of the September Medication Administration Record (MAR) for Resident #59, revealed the resident was monitored for pain with a rating scale every shift (excluding when the resident had a 0-pain score) was as follows: On 09/03/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 1, indicating mild pain as documented by Staff DD Registered Nurse. On 09/13/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 4, indicating moderate pain as documented by Staff CC Licensed Practical Nurse. On 09/17/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 5, indicating moderate pain as documented by Staff GG Nurse. On 09/18/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 2, indicating mild pain as documented by Staff HH Nurse. On 09/21/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 4, indicating moderate pain as documented by Staff CC Licensed Practical Nurse. On 09/24/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 4, indicating moderate pain as documented by Staff CC Licensed Practical Nurse. On 09/30/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 1, indicating mild pain as documented by Staff O RN (agency). 106021 Page 14 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Review of the September Medication Administration Notes for Resident #59 included the following: Level of Harm - Minimal harm or potential for actual harm On 9/1/2022 at 1:21 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not available entered by Staff N - Licensed Practical Nurse (agency). Residents Affected - Few On 09/1/2022 at 5:01 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not on hand was entered by Staff N - Licensed Practical Nurse (agency). On 09/2/2022 at 12:57 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not on hand was entered by Staff O - Registered Nurse (agency). On 09/2/2022 at 3:36 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not on hand was entered by Staff O - Registered Nurse (agency). On 09/12/2022 at 11:19 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG patient need a refill of this medication (pharmacy has been called) was entered by Staff K - Registered Nurse (agency). ON 09/13/2022 at 6:11 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG call pharmacy patient has no Oxycodone left was entered by Staff K - Registered Nurse (agency). Review of the August Medication Administration Record (MAR) for Resident #59, revealed the resident was not administered (excluding when resident was sleeping or had refused medication) her routinely scheduled Oxycodone-Acetaminophen 5-325 mg 29 times out of 186 opportunities. The dates/times and reason (if any) the routinely scheduled Oxycodone-Acetaminophen 5-325 mg was not given is as follows: On 08/09/22 at 12:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Q Registered Nurse (agency). On 08/09/22 at 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff R Licensed Practical Nurse (agency). On 08/10/22 at 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff S Registered Nurse (agency). On 08/20/22 at 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff T Registered Nurse. On 08/21/22 at 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff U Licensed Practical Nurse (agency). On 08/22/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff V - Licensed Practical Nurse (agency). On 08/23/22 at 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff N Licensed Practical Nurse (agency). On 08/25/22 at 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Q (continued on next page) 106021 Page 15 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Registered Nurse (agency). Level of Harm - Minimal harm or potential for actual harm On 08/25/22 at 4:00 PM and 8:00 PM no documentation (left blank). Residents Affected - Few On 08/26/22 at 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff N Licensed Practical Nurse (agency). On 08/26/22 at 4:00 PM and 8:00 PM no documentation (left blank). On 08/27/22 at 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff N Licensed Practical Nurse (agency). On 08/27/22 at 4:00 PM and 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff I - Registered Nurse. On 08/28/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff O - Registered Nurse (agency). On 08/29/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff O - Registered Nurse (agency). On 08/29/22 at 8:00 AM and 12:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff W - Licensed Practical Nurse (agency). On 08/29/22 at 4:00 PM and 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff Y - Registered Nurse. On 08/30/22 at 12:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff X Licensed Practical Nurse (agency). On 08/30/22 at 4:00 AM documentation of 5, indicating Hold/See Nurse Notes documented by Staff X Licensed Practical Nurse (agency). On 08/31/22 at 4:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff U Licensed Practical Nurse (agency). Review of the August Medication Administration Record (MAR) for Resident #59, revealed the resident was monitored for pain with a rating scale every shift (excluding when the resident had a 0-pain score) was as follows: On 08/02/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a X, indicating nothing as documented by Staff P - Registered Nurse. On 08/06/22 the evening shift (3:00 PM - 11:00 PM) no documentation (left blank). On 08/20/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 3, moderate pain as documented by Staff S - Registered Nurse (agency). On 08/30/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a NA, indicating 106021 Page 16 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 nothing as documented by Staff FF - Licensed Practical Nurse (agency). Level of Harm - Minimal harm or potential for actual harm Review of the August Medication Administration Notes for Resident #59 included the following: Residents Affected - Few On 08/9/2022 at 2:20 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG not rendered due to that the patient is sleeping documented by Staff Q- Registered Nurse (agency). On 08/9/2022 at 8:25 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG on Order documented by Staff R - Licensed Practical Nurse (agency). On 08/10/2022 at 12:34 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG wasn't given; we don't have the medication. Medication was order. documented by Staff S - Registered Nurse (agency). On 08/10/2022 at 4:28 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG we don't have the medication. It wasn't administered. Pharmacy consultation documented by Staff S Registered Nurse (agency). On 08/10/2022 at 4:35 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG we don't the medication, was notified to the pharmacy documented by Staff S-Registered Nurse (agency). On 8/20/2022 at 7:36 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG resident no want to take the medication at this time documented by Staff T- Registered Nurse. On 08/21/2022 at 10:51 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG med on order patient pain 0/10 documented by Staff V - Licensed Practical Nurse (agency). On 08/22/2022 at 1:00 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not available waiting for Pharmacy documented by Staff N - Licensed Practical Nurse (agency). On 08/22/2022 at 5:55 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG waiting from pharmacy documented by Staff V - Licensed Practical Nurse (agency). On 08/23/2022 at 6:14 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not on hand documented by Staff N- Licensed Practical Nurse (agency). On 8/25/2022 at 4:54 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG not rendered due to that the medication is not on the specific bin of the patient documented by Staff Q Registered Nurse (agency). On 8/26/2022 at 6:26 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not on hand. needs clarification documented by N- Licensed Practical Nurse (agency). On 08/27/2022 at 7:25 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not on hand. MD called awaiting call back documented by Staff N- Licensed Practical Nurse (agency). 106021 Page 17 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Level of Harm - Minimal harm or potential for actual harm On 08/30/2022 at 5:56 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG unavailable documented by Staff X - Licensed Practical Nurse (agency). On 08/31/2022 at 4:57 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG med n/a (not applicable) documented by Staff U - Licensed Practical Nurse (agency). Residents Affected - Few On 08/27/2022 at 7:36 AM provider called to put patient's Percocet on hold until delivered. awaiting call back documented by Staff N - Licensed Practical Nurse (agency). On 08/27/2022 at 10:47 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pharmacy called to verify script. Pt denies pain documented by Staff I -Registered Nurse. On 08/27/2022 at 10:49 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pharmacy called to verify script documented by Staff I Registered Nurse. On 08/28/2022 at 1:20 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending for pharmacy documented by Staff O- Registered Nurse (agency). On 08/28/2022 at 4:43 AM Medication Administration Notes and Nurses Notes Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending for pharmacy documented by Staff O - Registered Nurse (agency). On 08/29/2022 at 12:16 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending for pharmacy documented by Staff O - Registered Nurse (agency). On 08/29/2022 at 5:10 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending for pharmacy documented by Staff O - Registered Nurse (agency). On 08/29/2022 at 09:00 Nurse's Note Text: pharmacy contacted regarding Percocet prescription. writer notified of need for new prescription. Doctor's nursing staff notified, pending medical doctor (MD) receipt of message, will update with plan of care once aware documented by Staff W - Registered Nurse (agency). On 08/29/2022 at 9:18 AM Nurse's Note Text: Call received for physician, states that pain management/Percocet script is being managed by another physician. Call placed to the other physician, pending response documented by Staff W - Registered Nurse (agency). On 08/29/2022 at 12:15 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medical doctor (MD) aware med unavailable. pending scrip placement. patient denies any pain documented by Staff W - Registered Nurse (agency). On 08/29/2022 at 3:27 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending by pharmacy documented by Staff Y - Registered Nurse. On 08/29/2022 at 9:55 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending by pharmacy documented by Staff Y - Registered Nurse. On 08/30/2022 at 12:20 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 106021 Page 18 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 MG unavailable documented by Staff X - Licensed Practical Nurse (agency). Level of Harm - Minimal harm or potential for actual harm Review of the July Medication Administration Record (MAR) for Resident #59, revealed the resident was not administered (excluding when resident was sleeping or had refused medication) her routinely scheduled Oxycodone-Acetaminophen 5-325 mg 20 times out of 186 opportunities. The dates/times and reason (if any) the routinely scheduled Oxycodone-Acetaminophen 5-325 mg was not given is as follows: Residents Affected - Few On 07/03/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Z - Licensed Practical Nurse (agency). On 07/03/22 at 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff Y -Registered Nurse On 07/04/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Z - Licensed Practical Nurse (agency) On 07/04/22 at 4:00 PM and 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff Y- Registered Nurse On 07/05/22 at 4:00 PM and 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff J -Registered Nurse. On 07/06/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff AA - Licensed Practical Nurse (agency) On 07/18/22 at 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff CC -Licensed Practical Nurse. On 07/19/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Q - Registered Nurse (agency) On 07/21/22 at 4:00 PM and 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff Y - Registered Nurse On 07/22/22 at 8:00 PM documentation of 9, indicating Other/See Nurse Notes documented by Staff BB Licensed Practical Nurse. On 07/23/22 at 12:00 AM and 4:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Q - Registered Nurse (agency) On 07/25/22 at 12:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Q Registered Nurse (agency) On 07/27/22 at 12:00 AM documentation of 9, indicating Other/See Nurse Notes documented by Staff Q -Registered Nurse (agency) Review of the July Medication Administration Record (MAR) for Resident #59, revealed the resident was monitored for pain with a rating scale every shift (excluding when the resident had a 0-pain score) was as follows: 106021 Page 19 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Level of Harm - Minimal harm or potential for actual harm On 07/12/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 2, indicating mild pain as documented by Staff CC - Licensed Practical Nurse. On 07/22/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 10, indicating worst pain as documented by Staff Q - Registered Nurse (agency). Residents Affected - Few On 07/23/22 the night shift (11:00 PM - 7:00 AM) pain level was recorded as a 1, indicating mild pain as documented by Staff II - Nurse. Review of the July Medication Administration Notes for Resident #59 included the following: On 07/3/2022 at 12:11 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG meds not available, waiting for pharmacy to delivery as documented by Staff Z -Licensed Practical Nurse (agency). On 07/3/2022 at 4:22 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG meds not available, waiting for pharmacy to delivery as documented by Staff Z - Licensed Practical Nurse (agency). On 07/3/2022 at 5:53 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending by pharmacy as documented by Staff Y- Registered Nurse. On 07/3/2022 at 11:09 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG meds not available, pharmacy pending as documented by Staff Z - Licensed Practical Nurse (agency). On 07/4/2022 at 4:27 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pharmacy pending as documented by Staff Z - Licensed Practical Nurse (agency). On 07/4/2022 at 5:07 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending by pharmacy as documented by Staff Y - Registered Nurse. On 07/5/2022 at 9:10 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG waiting from pharmacy consultation as documented by Staff J - Registered Nurse. On 07/5/2022 at 9:11 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG waiting from pharmacy as documented by Staff J - Registered Nurse. On 07/6/2022 at 12:54 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication pending delivery from pharmacy as documented by Staff AA - Licensed Practical Nurse (agency). On 07/6/2022 at 5:30 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication pending delivery from pharmacy as documented by Staff AA - Licensed Practical Nurse (agency). On 07/18/2022 at 6:15 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG medication not available as documented by Staff CC - Licensed Practical Nurse. 106021 Page 20 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/19/2022 at 12:39 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG not given due to that this medication is not inside the patient's specific bin as documented by Staff Q -Registered Nurse (agency). On 07/19/2022 at 4:38 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG not given due to that this medication is not on the patient's specific bin as documented by Staff Q -Registered Nurse (agency). On 07/21/2022 at 4:14 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending by pharmacy as documented by Staff Y - Registered Nurse. On 07/21/2022 at 9:34 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG pending by pharmacy as documented by Staff Y - Registered Nurse. On 7/22/2022 at 8:19 PM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG resident sleeping as documented by Staff BB - Licensed Practical Nurse. On 07/23/2022 at 12:08 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG this medication needs to be reordered and the patient/resident does not have this in her patient's specific bin as documented by Staff Q -Registered Nurse (agency). On 0 7/23/2022 at 3:00 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG this medication is not given due to that it is not on the patient's specific bin as documented by Staff Q -Registered Nurse (agency). On 07/25/2022 at 1:07 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG not rendered due to that the patient is sleeping as documented by Staff Q -Registered Nurse (agency). On 07/27/2022 at 12:06 AM Medication Administration Note Text: Oxycodone-Acetaminophen Tablet 5-325 MG the patient refused as documented by Staff Q -Registered Nurse (agency). Review of the facility's policy titled, Administering Oral Medications with a revised date of October 2010, revealed the following: In the Section labeled Documentation, it is documented follow documentation guidelines in the procedure entitled Documentation of Medication Administration (requested by surveyor and was informed that it is in the Administering Oral Medications policy). In the Section labeled Reporting, it is documented to 1. Notify the super 106021 Page 21 of 22 106021 10/20/2022 Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

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 observations and interviews the facility failed to ensure proper storage of medications as evidenced by failure to lock medication carts and secure for 1 out of 2 medication carts observed on the facility's 4th floor. 2) Failed to ensure medication refrigerators are plugged into emergency outlet in event of a power outage. There were 140 residents residing in the facility at the time of this survey. The findings included: During a tour of the facility conducted on 10/18/22 at 4:57 PM, an observation was made of a medication cart that had been left unlocked and unattended in the main hallway of the 4th floor near room [ROOM NUMBER]. Photographic evidence was obtained of this unlocked cart. On 10/18/22 at approximately 5:00 PM, the surveyor asked a passing Certified Nursing Assistant (CNA) which nurse was responsible for the cart, and the CNA replied that it was Staff I, RN. Staff I then came to the surveyor and was notified of her unlocked medication cart. The nurse did not verbally respond but did walk over and lock the cart. On 10/18/22 at approximately 6:30 PM the Director of nursing was informed of the observations. Observation and interview conducted by the Life Safety Surveyor with the Maintenance Director and the Regional Facilities director on October 20, 2022, between the hours of 11:00 AM and 2:00 PM on the second, third and fourth floors in the medication rooms at the nurses' stations revealed the medication refrigerators are not connected to the emergency electrical branch. Unapproved connections to the medical refrigeration can pose harm and danger to patient's medicines in the event of a power failure or electrical shortage. 106021 Page 22 of 22