Health inspection·July 2, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a computerized record review of the nurses' note dated 05/26/25 at 11:29 PM by Staff D, Licensed Practical Nurse (LPN) she documented and revealed, Resident resting in bed no sign of distress noted . Resident face has redness On 07/02/25 at 4:28 PM an interview was conducted with Staff B, Certified Nurse Assistant CNA (assigned to the resident at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM in which she was working on the 11 PM - 7:30 AM shift), in which she revealed that when she came in that night and did her rounds, after 11 PM that night, both she and the nurse, Staff C, LPN, saw a little red rash on one of the resident's cheeks and on his chin. On 07/02/25 at 4:24 PM a telephone call was attempted, but the message stated that, this number cannot take calls, at this time, Staff A, CNA (was assigned to Resident #1 just before the event occurring on Tuesday 05/27/25 at 4:30 AM, in which she was working on the 3 PM - 11:30 PM shift), was unavailable for interview, during this survey, in order to discuss Resident #1's skin condition, at the time.On 07/02/25 at 4:26 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system, and it is not available to leave a message, Staff D, (was assigned to Resident #1 just before the event occurring on Tuesday 05/27/25 at 4:30 AM and who had been working on the 3 PM - 11:30 PM shift), was unavailable for interview, during this survey, in order to discuss Resident #1's skin condition, at the time.An interview was conducted on 07/02/25 at 4:58 PM with the Facility Registered Nurse (RN)/Risk Manager, in which she acknowledged that Resident #1 did have some type of redness, bruising and swelling on his forehead and chin, to her knowledge, however, she indicated that she did not learn about this until it was brought to her attention (when she was informed) by the resident's son, after Resident #1 had already been transferred out of the facility and to the hospital, after the date of: Thursday 05/29/25 at 6:33 PM---2 days later. She stated that she was not informed of this by the assigned nurse for the resident, at the time in which it had been documented, on Tuesday 05/27/25. The Risk Manager also acknowledged that there had been no further description nor details documented regarding Resident #1's skin condition, in the facility's progress notes. Moreover, the Facility Risk Manager revealed that she had documented, Hospital staff informed the resident's son that the resident was admitted with the above bruises, as documented in the report provided to Agency for Healthcare Administration (AHCA), by the facility's Risk Manager, dated 06/03/25 6:01:45 PM. The Risk Manager also indicated in the AHCA report that, On May 26, 2025, the 3 PM - 11 PM staff stated that upon their initial rounding on the resident, they observed him with redness on the left chin, the redness appeared recent And, the Risk Manager further documented in this same report that, during the interview process, the 11 PM- 7 AM staff expressed that they saw a bruise on the left side of the resident's cheek. And documented this on the resident's transportation form before he was transported to the Hospital. The Risk Manager subsequently described, as documented, the resident's skin abrasions after hospital transfer as: The first skin abrasion was visible approximately an inch above the resident's right brow line approximately the size of a nickel, with pinpoint red bumps visibly around the area, no swelling or rise was observed; the second skin abrasion was visible under the resident's lip towards the left corner of his mouth, the skin abrasion was blotchy/irregular shaped and approximately 2 inches, also with no swelling or skin elevation> The Risk Manager further acknowledged that both of these notations were also in the report that she submitted to AHCA. Record review of the Resident #1's Skin Care plan initiated 10/30/20 and revised 05/08/25 indicated Focus: Status/post Hospitalization on 05/08/25 . Interventions: Dermatology consult as needed . Topical treatments as ordered Goal: Resident #1 will be free of skin breakdown by next review date.There had been no mention or documentation in the record, prior to this time referencing a redness to the resident's face from Thursday 05/01/25 at 6:23 AM, in which Resident #1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106038 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sent out to the hospital, returned to the facility on Thursday 05/08/25 at 9:25 PM until the nurses' notation on Monday 05/26/25 at 11:29 PM. Neither was there any further information describing the exact location on the resident's face that this was noted, whether the skin was intact, bruising, swollen, clean and dry. Furthermore, there was no notation in the record that this had been reported to either the Supervisor or Unit Manager on duty, nor whether any further facial skin assessment or follow-up had been done, for this resident, at the time.2) Review of the facility policy titled Change of Condition provided by the DON effective 05/12/25 documented in the Policy Statement: . II Standard: Identify, report, document and respond to a resident's change of condition to ensure timely and appropriate care. III. Definitions: A. Change of Condition: A new, worsening, or unexpected clinical development that: Threatens life or may lead to hospitalization, or Requires starting, stopping, or adjusting treatment, or Alters the residents' physical, mental, or psychological status. IV. Procedures: A. Detect the Change: All direct-care staff continuously observe deviations from baseline such as but not limited to: New or worsening pain, New changes in vital signs, Acute mental-status change, New skin discoloration or breakdown, New onset/change of mobility or functional decline, Abnormal event or occurrence. B. Notification: Relay observations to LPN/RN/Supervisor/DON to assist as necessary. Contact the primary or on-call MD/NP/PA promptly, for potentially life-threatening situations (e.g. possible Sepsis, Stroke, Uncontrolled pain). a. Provide concise information: vitals, assessment and observation findings, labs, code status, and recommended actions. b. Initiate treatments, diagnostic tests, or transfers as prescribed. Inform the resident (as able) and the designated representative of the change and provider orders. C. Document in the HER, create a comprehensive progress note on the same shift that includes: Assessment details and clinical findings, Provider notification (name, time, information shared), Interventions carried out and resident's response and Follow-up evaluation results.Computerized record review of the nurses' progress note dated Tuesday 05/27/25 at 5:16 AM by Staff C, LPN, on the 11 PM - 7:30 AM shift, revealed that she documented, Call placed to resident family member. Message left on answering machine informing of resident transfer to the hospital. Resident #1 was transferred to the hospital due to lethargy, shortness of breath, and labored breathing.On 07/02/25 at 4:47 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system and it is not available leave a message. Staff F, RN, Part-time Night Supervisor of the entire building (was assigned to Resident #1's unit at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM she will often either work on the 7 AM - 3:30 PM shift or on the 11 PM - 7:30 AM shift), was unavailable for interview, during this survey, in order to discuss whether or not the resident's representative had been contacted.On 07/02/25 at 4:43 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system, and it is not available to leave a message, Staff C, (was assigned to Resident #1 at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM in which she was working on the 11 PM - 7:30 AM shift), was unavailable for interview, during this survey, in order to discuss whether or not the resident's representative had been contacted.During an interview conducted on 07/02/25 at 2:38 PM, with Staff E, RN, (who was assigned to Resident #1 just the time after the event had occurred earlier on Tuesday 05/27/25 at 4:30 AM, in which she was working on the 7 AM to 3:30 PM day shift) she revealed that she had not made any phone calls, at any time during her shift, to Resident #1's family in order to ensure that they had been informed of the resident's hospital transfer.During a subsequent side-by-side record review and interview with the Risk Manager on 07/02/25 at 5:20 PM, it was revealed, according to the progress notes in the facility record, that there was only one (1) note regarding Resident #1's family being notified via voice message (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106038 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete only. Subsequently, the Risk Manager acknowledged that there was no additional notation to show that the resident's family ever actually received this information from the facility, nor that the facility made any other attempts to contact and notify the resident's family of the resident's transfer out of the facility to the hospital.There were no other documented follow-up phone call attempts made by the facility to verbally inform the resident's representative of the resident's changed in condition or status, nor of his transfer to the hospital. And, there was no evidence to show that the facility had actually spoken to and informed the son. The DON further recognized and acknowledged on 07/02/25 at 5:45 PM that, Resident #1's facility identified 'face with redness and rash on one of his cheeks and on his chin,' should have been documented in detail to include whether or not the skin was intact, bruising, swollen, clean and dry, size and include a description and exact location on the resident's face along with any further facial skin assessment or follow-ups, reported to the Supervisor, to her and to the Doctor notified, as applicable or as warranted. The DON also acknowledged that the resident's representative should have been notified and ensured that documented attempts or efforts were made to contact them. Event ID: Facility ID: 106038 If continuation sheet Page 4 of 4