Health inspection·December 22, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to refer a resident, for a Preadmission Screening and Resident Review (PASRR) Level II screening for one (Resident #128) of one resident out of seventeen residents receiving health rehabilitation services for Mental Illness (MI) and/or Intellectual Disability (ID) who exhibited behaviors. There were 207 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR) Program Policy and Procedure (effective 4/2017, reviewed 10/2022) documented the following: Intent: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission screening and Resident review, in accordance with State and Federal Regulations. Definitions: For purposes of this policy: 1) An individual is considered to have a mental disorder is the individual has a serious mental disorder, 2) An individual is considered to have an intellectual disability if the individual has an intellectual disability, 3) or is a person with a related condition and 4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. Procedure: 1) A facility will coordinate assessments with the pre-admission screening and resident review (PASRR) program as stated under Federal regulations to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes a) Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care, b) referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Observation of Resident #128 on 12/20/22 at 7:38 AM revealed the resident sitting up in bed with the television on, eating breakfast. Floor mats were noted. Review of the Preadmission Screening and Resident Review (PASRR) Level I for Resident #128 on 12/20/2022 at 9:39 AM documented the following: 1) PASRR Level I was completed on 10/07/2020 at a local Hospital; 2) Section I, PASRR Level I Screen Decision Making Mental Illness (MI) or suspected MI were not checked, the section was marked as N/A (non-applicable); 3) Section II, Other Indications for PASRR Screen Decision-Making were checked No; 4) Section IV: PASRR Screen Completion were checked for-No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR not required and 5) Resident admitted to the facility on [DATE]. Page 1 of 7 106094 106094 12/22/2022 Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Demographic Face Sheet for Resident #128 documented the resident was admitted on [DATE] with diagnoses to include acute respiratory failure and Parkinson's disease. The resident was diagnosed with Schizoaffective disorder on 5/27/2021, anxiety disorder on 3/08/2022 and psychotic disorder with hallucinations on 12/09/2022. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #128 dated 9/23/2021 documented the PASRR for the resident not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and the Brief Interview for Mental Status (BIMS) Summary Score was not scored, indicating severe cognitive impairment. Review of the MDS Quarterly for Resident #128 dated 11/27/2022 documented (BIMS) Summary Score was not scored, indicating severe cognitive impairment and is extensive assistance to total dependence with one-two+ person physical assist for ADLs (activities of daily living). Review of the Physician' s Order Sheets (POS) and Electronic Medication Administration Records (EMAR) for Resident #128 for October 2022, November 2022 and December 2022 documented the resident was receiving antipsychotic medications and antianxiety medications: Pimavanserin Tartrate 34 mg (milligrams) cap (capsule) 1 cap PO (by mouth) one time a day for psychosis, start date 9/03/2022; Alprazolam 0.5 mg tab (tablet) 1 tab PO TID (three times a day) for anxiety disorder, start date 9/18/2022 and Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder, start date 10/05/2022. On 9/20/2022, the resident was prescribed Lorazepam Solution 2 mg/ml (milliliters) inj (inject) 0.25 ml IM (intramuscular) every 8 hours PRN (as needed) for severe anxiety/agitation for anxiety disorder. Resident #128 exhibited behaviors on the following dates: 9/20/2022 and 10/01/2022 and received PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety was reinstated for 14 days, and on 10/05/2022 received Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder. Review of the Care Plans for Resident #128 documented the resident had care plans for the following: Insomnia (initiated date 3/15/22), Psychotropic Medications (initiated date 3/15/2022), Anxiety (initiated date 3/15/2022) and Schizoaffective Disorder and Organic Brain Syndrome (initiated date 3/15/2022). The care plan for Schizoaffective Disorder and Organic Brain Syndrome (initiated date 3/15/2022) documented: Focus: Resident is on antipsychotic medication for management of behavioral problem. Resident has diagnosis of Schizoaffective Disorder and Organic Brain Syndrome; Goal: Resident will have reduced incidents of mood or behavior change by NRD (next review date); Interventions: Administer medications as ordered and Assess behavior pattern daily. Review of the Progress Notes for Resident #128 documented the following: On 9/20/2022, a psychotropic note documented the resident refusing to take oral medication and striking out at staff. PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety was reinstated for 14 days; On 10/01/22, the resident was observed screaming with aggressive behavior towards staff and was given PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety and on 10/05/22, the resident was observed being aggressive towards staff while helping with ADLs. The MD (medical doctor) was contacted and ordered to start the resident on Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder. Interview and record review with Staff A, Registered Nurse (RN) on 12/21/2022 at 10:30 AM. Staff A stated, She is alert and oriented times one. She is extensive to total care for ADLs. Her diagnoses include anxiety disorder, Schizoaffective disorder, psychosis, and insomnia. She takes Pimavanserin Tartrate 34 mg cap 1 cap PO one time a day for psychosis, Melatonin 1 mg tab 2 tabs PO HS for insomnia, Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder and Alprazolam 0.5 mg tab 1 106094 Page 2 of 7 106094 12/22/2022 Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tab PO TID for anxiety disorder. The Olanzapine was ordered on 10/05/22. Sometimes she exhibits behaviors, and they are documented on the EMAR and progress notes. Progress notes on 10/05/22, resident aggressive to staff and MD ordered and started on Olanzapine. On 10/01/22 she was screaming and was given Lorazepam. On 9/20/22 psychotropic note resident refusing to take oral medication and striking out at staff. PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety was reinstated for 14 days. Residents' mood and behavior are being monitored. Interview with Staff B, CNA (Certified Nursing Assistant) on 12/21/2022 at 10:40 AM via Spanish translator. Staff B revealed, the resident requires extensive care, and the care depends on her mental state. Staff B reported she has witnessed the resident with anxiety, repeating words and confused. Sometimes the resident will fight when care is being given. Interview with the Social Services Director on 12/21/2022 at 12:17 PM. The Social Services Director stated: The PASRR for 10/07/20 did not have any diagnosis on it. This diagnosis of Schizoaffective disorder is a new one. I have to be notified by nursing when there is a change in behaviors. Once I am notified, then I request a resident review of the PASRR Level I. They look at MDS, psych notes and they are reviewed by [ local state agency] and they are pretty quick about it. I was not notified by nursing about new diagnosis and behaviors. Subsequent interview on 12/21/22 at 1:03 PM, the Social Services Director revealed she did a Resident Review Evaluation Request on 8/08/22. [local state agency] responded with a letter dated on 8/11/22 requesting Psychiatric Progress Notes and/or Psychiatric Evaluations that indicate diagnoses and current nursing progress notes for that month. On 8/22/22, the readmission Screening and Resident Review Screening; Letter documented: We can't complete the screening. The review was closed due to an incomplete referral packet. Subsequent interview on 12/21/22 at 1:31 PM, the Social Services Director stated, When I looked into the computer, I didn't see it. I went to [local state agency] website and realized I did it in August 2022. The resident had a diagnosis of Schizoaffective disorder on 6/19/2022. Interview with the Director of Nursing (DON) on 12/21/2022 at 12:42 PM. The DON stated, Our pharmacy will send me a recommendation for a new diagnosis to be added and then the PASRR should be done. The pharmacy notified me of her new diagnosis. Once I receive the new diagnosis, I am to present the diagnosis and pharmacy recommendation to the Social Worker Director so that she can review the PASRR. Review of the PASRR Resident Review Evaluation Request Form for Resident #128 dated 8/08/22 documented the resident had a significant change date of onset on 8/01/22 which was an increase in behavioral, psychiatric, or mood-related symptoms. The form was completed by the Social Services Director. Review of the Florida PASRR Level II Receipt of Referral Packet Notice of Missing Clinical Documentation for Resident #128 dated 8/11/22 documented a local state agency requested psychiatric progress notes and/or psychiatric evaluations that indicate diagnoses and current nursing progress notes for that month for the resident. Review of the local state agency letter dated 8/22/22 for Resident #128 documented the following: We can't complete the screening. The review was closed due to an incomplete referral packet. 106094 Page 3 of 7 106094 12/22/2022 Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure pharmaceutical services and procedures were being followed for 1 (3rd Floor North Cart) out of 5 medication carts observed as evidenced by an incorrect narcotic count for Resident # 89. There were 206 residents in the facility receiving care and services at the time of this survey The findings included: During observation of the 3rd Floor North Cart on 12/20/22 at 10:24 AM with Licensed Practical Nurse (Staff C), the Narcotic Count for Resident #89 was incorrect- Alprazolam 0.25 milligram (MG) (1) tablet count was twenty-one (21) in narcotic book, last signed out on 12/19/22 at 21:40. The Medication Bingo card count was twenty (20), the Electronic Medication Administration Record (EMAR) revealed resident #89 received Alprazolam 0.25 milligram (MG) (1) tablet on 12/20/22 at 8:04 AM (2 hours prior to this cart observation). Review of the medical records for Resident #89 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Anxiety Disorder Unspecified. Review of the Physician's Orders Sheet for December 2022 revealed Resident #89 had orders that included but not limited to: Alprazolam 0.25 MG (1) tablet by mouth every 12 hours related to anxiety disorder. Record review of Resident # 89's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented-Brief Interview of Mental Status Score (BIMS)-14, on a 0-15 scale indicating the resident is cognitively intact. During an interview on 12/20/22 at 10:29 AM, Staff C, when asked what the facility policy is on signing out narcotics, Staff C stated: Usually I sign when I remove the medication from the cart, today I thought I signed, I don't know what happen today. We are supposed to sign the medication out immediately in the narcotic book when we take it off the bingo card and signed off on the Electronic Medication Administration Record (EMAR) after the medication is given to the patient. During an interview on 12/21/22 at 09:30 AM, the Director of Nursing (DON) stated: I heard about what happened with the narcotics with the nurse and I wanted you to know that we did an in service on controlled substances with all the nurses in the facility . The policy at this facility is to sign off on the narcotics immediately when taken out of the bingo card and signed off as given on the EMAR after giving the medications to the resident. After the incident I immediately give the nurse (Staff C), an in-service on narcotics, my Assistant Director of Nursing, Nurse Educator (Staff D), conducted an audit on 12/20/22 on every narcotic book and summarized that this was an isolated situation. We also did a new in-service on 12/20/22 with all the other nurses in the facility. Based on our findings this was an isolated event. The nurse in question has been here for 9 years and she is a very good nurse. Review of the facility's policy titled Controlled Substances revision date 12/7/2022, states: controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. 106094 Page 4 of 7 106094 12/22/2022 Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156

F 0755 Upon Administration: Level of Harm - Minimal harm or potential for actual harm a. The nurse administering the medication is responsible for recording: 1. Name of the resident receiving the medication Residents Affected - Few 2. Name, Strength, and Dose of the medication 3. Time of administration 4. Method of administration 5. Quantity of the medication remaining 6. Signature of nurse administering medication 106094 Page 5 of 7 106094 12/22/2022 Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156

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, it was determined that the facility failed to ensure a medication error rate below five percent. During the medication administration observation task, there were 29 opportunities for errors and two medication errors were observed resulting in an error rate of 6.9%. This affected 2 out of 3 residents observed (Resident #39 and Resident #261). There were 207 residents admitted to the facility at the time of the survey. Residents Affected - Few The findings included: 1. During the medication observation on 12/21/2022 at 8:17 AM on the 2nd floor Meadow cart with Staff E, Registered Nurse. Staff E applied Diclofenac gel 1 % to Resident #261's bilateral knees. When Staff E was asked whether the Diclofenac was to be applied to the resident's neck, Staff E reported, they apply the medication to the resident neck, knee's and wherever the resident has pain. Review of Resident #261's medical record revealed, the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to, Unspecified Fracture of the upper end of the right humerus. The resident had a physician order dated 12/16/2022 for Diclofenac Sodium 1 % Gel, apply to the neck topically three times a day for pain moderate, pain scale 4 - 6. 2. During the medication observation on 12/21/2022 at 9:28 AM on the 4th floor Hibiscus Isle, North cart with Staff F, Registered Nurse. Staff F administered Iron 325 mg/65 mg(milligrams) 1 tablet by mouth to Resident #39. Review of resident #39's medical record revealed, the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Anemia and Atherosclerotic Heart Disease. The resident had a physician order for Ferrous Sulfate Elixir 220 (44 Fe) mg/5 ml (milliliters), Give 7.5 ml by mouth one time a day for aid with H/H (hemoglobin/hematocrit) repletion related to Anemia unspecified dated 6/23/2021. The Director of Nurses was interviewed on 12/21/22 at 03:16 PM, to discuss the medication administration observations for Resident #39 and Resident #261. The facility's policy for medication administration was requested. During the review of the facility's Medication Administration policy dated 03/02/2018 and reviewed on 11/10/2022, the policy and procedure documented, the policy Statement included: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so Policy Interpretation and Implementation: 2) Medications are administered in accordance with written orders of the prescriber. 106094 Page 6 of 7 106094 12/22/2022 Riviera Health Resort 6901 Yumuri Street Coral Gables, FL 33156

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to demonstrate effective plans of action were implemented to correct identified quality deficiencies in problem-prone areas as evidenced by repeated deficient practice identified during consecutive annual surveys related to Pharmacy Services (F755) The facility's QAPI Program Plan, reviewed November 2022, documented, Quality Measures - shall be reviewed via monthly report by the MDS Coordinator to team members of the QA committee. Findings shall be reported by the department whose Quality Indicator met the threshold and provided in monthly report to the QAPI Nurse Director. Survey findings: Past deficiencies - obtained from previous survey visits with ongoing monitoring. for past deficiencies target will included the exact deficiency. The department director will submit a monthly report for the QAPI Nurse Director. For current deficiencies-a plan of correction (POC) will be developed and implemented. Collaboration with department directors, QAPI Nurse Director and Administrator and the CEO. During the most recent prior annual recertification survey completed at the facility, with an exit date of 06/30/21, it was noted that the facility was cited at F755 - Pharmacy Services - related to an inaccurate narcotic count. During the current annual recertification survey, with an exit date of 12/22/22, it was determined that the facility was not in compliance with the regulations for F755 - Pharmacy Services - related to inaccurate narcotic reconciliation. 106094 Page 7 of 7