Health inspection·May 5, 2022

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to post daily nurse staffing information, in a timely manner, prior to the beginning of the shift for two of three shifts and three of four days, during the Re-certification survey. Residents Affected - Few The findings included: Review of policy titled Nurse Staff Information for Posting effective date 03/01/06, included: The facility must document compliance with staffing standards and post daily staffing information based on State and Federal regulatory standards. Federal Requirement for Nurse Staff posting: The facility must post the following information related to Nurse staffing on a daily basis: 1. Facility name; 2. The current date; 3. Total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a. Registered Nurses b. Licensed Practical Nurses c. Certified Nurse Aides; and 4. Resident Census. The data must be posted in a clear and readable format and be displayed in a prominent place readily accessible to residents and visitors. On 05/02/22 at 4:30 PM, the posted Nurse Staff schedule for the 3-11 PM shift was still noted to be Blank. On 05/03/22 at 8:37 AM, the posted Nurse Staff schedule for the 7-3 PM shift was noted to be Blank. On 05/03/22 at 9:32 AM, the posted Nurse Staff schedule for the 7-3 PM shift was still noted to be Blank. On 05/04/22 at 9:35 AM, it was noted that the Nurse Staff schedule dated 05/03/22 was still posted on today's date of 05/04/22. Photographic evidence obtained. During an interview conducted on 05/04/22 at 9:54 AM with the Director of Nursing (DON) she was made aware of the nurse staffing posting not being properly recorded on the form, in a timely manner, before the beginning of both the evening and day shifts on 05/02/22, 05/03/22 and 05/04/22, in the main facility entryway corridor. She stated that the nurse staffing posting should be posted by the Staffing Coordinator or by the day or evening shift Supervisors before the beginning of each shift; this was not done. Page 1 of 5 106038 106038 05/05/2022 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to assure that psychotropic drugs are limited for 14 days unless the prescribing physician document their rationale for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #69). The findings included: Review of the facility's policy titled Psychotropic Medication Clinical Guidelines revised on 10/06/2017 showed the following: PRN (as needed) orders for psychotropic drugs are limited to 14 days, except when the attending Physician, or prescribing practitioner believes that it is appropriate for the PRN orders to be extended beyond 14 days. Then he/or she should document the rational in the resident's medial chart and indicate the duration of the PRN order. It further showed that the Pharmacist should contact the attending physician regarding any concerns with psychotropic medications. A review of the medical chart showed that Resident #69 was admitted [DATE] and readmitted on [DATE]. Diagnoses included Dementia, Dysphagia, and abnormal weight loss. Further review of the Physicians orders showed an order for Lorazepam 0.5 mg by mouth every 12 hours PRN for anxiety disorder which was dated 02/24/22. Review of the PRN Medication Administration History from 03/01/22 to 03/31/22 showed that Resident #69 was given Lorazepam PRN on the following 12 dates: 03/01/22, 03/03/22, 03/05/22, 03/08/22, 0310/22, 03/15/22, 03/18/22, 03/19/22, 03/25/22, 03/26/22, 03/29/22 and 03/31/22. This showed that the order for Lorazepam PRN continued passed 14 days. Review of the PRN Medication Administration History from 04/01/22 to 04/30/22 showed that Resident #69 was given Lorazepam PRN on the following 10 dates: 04/01/22, 04/04/22, 04/06/22, 04/07/22. 04/08/22, 04/09/22, 04/12/22, 04/13/22, 04/14/22 and 04/15/22. Further review of the electronic chart did not contain any documentation that the facility's Pharmacist contacted the prescribing physician regarding the use of PRN medication beyond 14 days. In an interview conducted on 05/03/22 at 2:50 PM, with the facility's Pharmacist, she stated that any psychotropic medication that are passed the 14 days she will contact the prescribing physician and will rewrite a new order for another 14 days if needed. When asked if she knew that Resident #69 continued receiving a psychotropic medication that was given passed the 14 days limit, she said no. When asked if she contacted the prescribing physician regarding Resident #69's PRN order that went beyond the 14 days, she said no. In an interview conducted on 05/05/22 at 11:55 AM, with the facility's Director of Nursing, she stated that PRN psychotropic medication are limited to 14 days unless the prescribing physician wants it for a longer period. In this case, the facility's Pharmacist keeps an updated list and will contact the prescribing physicians when needed. She also stated that the facility's supervisors are the back up when the Pharmacist is not able. 106038 Page 2 of 5 106038 05/05/2022 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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, it was determined that the facility failed to ensure that menu foods were served palatable, at an appetizing temperature, and attractive during dining observations for 1 of 1 resident (Resident #5). Residents Affected - Few The findings include: In an interview conducted on 05/03/22 at 12:05 PM with Resident #5's roommate's family, they stated Resident #5 needs full assistance with all his meals and cannot eat on his own. At times, the facility does not have enough staff assisting during mealtime, and they place the meals in the room and walk out. The family further said they told Resident #5's family member what was happening when she was not in the facility. A chart review showed that Resident #5 was admitted on [DATE] and is with swallowing problems related to dysphagia. He is at a potential risk for aspiration and weight loss. It further showed that Resident #5 is at cognitive impairment related to his diagnoses of Alzheimer's disease. In a phone interview conducted on 05/03/22 at 9:11 AM with Resident #5's family member, she stated that she was concerned with the facility staff feeding him his meals and liquids too fast. She reported that her brother had aspiration pneumonia in the past and was worried that it may happen again. She further stated that a family member who comes in daily told her that she often sees Resident #5 fed too fast and that on the days that she is not in the facility, her brother is the last Resident to get his meal tray. The lunch tray arrived on the unit in an observation conducted on 05/03/22 at 11:38 AM. At 12:02 PM, 24 minutes later, the lunch tray was taken out of the meal cart in the hallway and brought into Resident #5's room. The meal was placed on the side table. In this observation, Resident #5's family member arrived at 12:10 PM and started assisting Resident #5 with his lunch meal (which was 32 minutes later). In an observation conducted on 05/04/22 at 7:45 AM, the breakfast meal cart arrived at the Delta-Green Unit. At 8:15 AM, 30 minutes later, the breakfast tray was taken from the meal cart and brought into Resident #5's room. Staff A, Certified Nursing Assistant (CNA), was at the bedside. Staff A was told by Staff C, a Licensed Practical Nurse, to wait for the breakfast meal because she needed to go into the kitchen and get the honey thickened liquids for Resident #5. At 8:21 am, about 36 minutes later, Staff B, Certified Nursing Assistant, started assisting Resident #5 with his breakfast tray. She was done helping the Resident at 8:32 am, 11 minutes later. In an interview conducted on 05/05/22 at 2:00 PM, with the facility's Director of Nursing, she was informed of the findings. 106038 Page 3 of 5 106038 05/05/2022 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review the facility failed to provide food items that accommodate preferences for 4 of 4 sampled residents (Residentd #4, #46, #5 and #50). Residents Affected - Few Findings included: In an observation conducted on 05/03/22 at 11:25 AM, in the Delta-Green Unit, Resident #50 was observed eating his lunch meal in the dining room. Closer observation showed a meal ticket with the following: extra 2 soups and extra 2 margarines. His lunch meal consisted of only 1 soup (instead of 2) and no margarines (Photographic evidence obtained). In an observation conducted on 05/04/22 at 7:52 AM, in the Delta-Green Unit, Resident #46 was observed in the dining room eating his breakfast meal. Closer observation showed a meal ticket with the following: No added salt, breakfast with 2 extra margarines. Resident #46's plate showed eggs, toast, bacon and 1 pack of margarine (Photographic evidence obtained). In this observation, Resident #46's stated I do not have enough margarine. In an observation conducted on 05/04/22 at 7:52 AM, in the Delta-Green Unit, Resident #4 was observed in the dining room eating his breakfast meal. Closer observation showed a meal ticket with the following: extra yogurt and extra prune juice. The breakfast meal did not have the extra yogurt, or the extra prune juice as requested (Photographic evidence obtained). In an observation conducted on 05/04/22 at 11:25 AM, in the Delta-Green Unit, Resident #50 was observed in the dining room eating his lunch meal. Closer observation showed a meal ticket with extra double portion of meat. His lunch plate showed a fruit salad with only 1 serving of cottage cheese (Photographic evidence obtained). In an interview conducted on 05/03/22 at 12:10 PM, Resident #5's family member, stated that when she comes into the facility 3 times a week to help her brother with his lunch meal it takes her about 1 hour to feed him and he usually consumes 100% of his meals. She also said that in the past, she was not provided with meal choice options and only recently after complaining she received a menu to make the choices for Resident #5. According to her, they often do no place soups on the meal tray even when requested. In an interview conducted on 05/05/22 at 11:18 AM, the facility's Food Service Director stated that upon admission, the resident's food preferences and food likes are placed into the system and generated on the meal tickets. If residents cannot say what they like, they would speak to the residents' families. She further reported that the kitchen supervisors would check for the accuracy of the meal tickets in the morning shift and the evening shift. She does random checks on the tray line to ensure that the right foods are placed on the meal tickets. According to the Food Service Director, any updated food preferences are changed in the electronic system. 106038 Page 4 of 5 106038 05/05/2022 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to provide appropriate fluids to a dialysis resident who was prescribed by the physician to have fluid restriction for 1 of 1 sampled resident (Resident #7). The findings included: A record review showed that Resident #7 was admitted on [DATE] with the following diagnoses: End stage renal disease, cognitive deficit and cerebral infarction. Further review of the physician orders showed an order for fluid restriction with meals: Breakfast 240 ml (milliliters), Lunch 240 ml, Dinner 240 ml, for a subtotal of 720 ml, which was dated on 04/02/21. In an observation conducted on 05/03/22 at 12:30 PM, Resident #7 was noted in his room. He was observed drinking 8 ounces (240 ml) of coffee, and 12 ounces (360 ml) of water in a Styrofoam cup was noted on the side table. In this observation, Resident #7 was asked by Surveyor if he was on a fluid restriction and he could not give any clear answers. In an observation conducted on 05/04/22 at 8:25 AM, Resident #7 was eating his breakfast meal with staff in the room. Closer observation showed a meal ticket with the following: Regular, liberalized ml fluid restriction, with small portion of starch. It further showed Miscellaneous 240 ml fluids with meals and no other liquids with meals. Closer observation of the breakfast meal showed the following: 12 ounces (360 ml) of water in a Styrofoam cup, 8 ounces (240 ml) of water in a second cup, 8 ounces (240 ml) of juice and 8 ounces (240 ml) of coffee. This accumulated to 1080 milliliters of liquids at one meal which exceeded the 240 ml of fluids for breakfast. In an interview conducted on 05/05/22 at 10:30 AM, with Staff D, Certified Nursing Assistant, she stated Resident #7 is always asking for a cup of coffee after he comes back from dialysis and will usually drink it all. She further said Resident #7 already has 8 ounces (240 ml) of water at the bedside, and he gets an additional 8 ounces of water with his meal trays. Staff D also said Resident #7 does not always drink his extra water, but she puts it at the bedside just in case. She further stated that extra water needs to be placed for all residents. When asked by Surveyor if she knew that Resident #7 was on a fluid restriction she said yes. She was also asked what being on a fluid restriction means. She said the following: not giving residents too much water or too much juice. 106038 Page 5 of 5