Health inspection·January 11, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to promote dignity and respect for two residents (#41 and #93) out of 28 sampled residents. As evidenced by a Certified Nursing Assistant (CNA) was observed standing while feeding Resident #41 and Resident #93 not having any food while his roommate was being fed and eating food. There were 143 residents residing in the facility at the time of the survey. The findings included: On 01/08/24 at 12:15 PM Certified Nursing Assistant (CNA), (Staff B) was observed standing over the bed of Resident #41 and feeding him lunch from the lunch tray. On 01/08/24 at 12:15 PM Resident #93's roommate was eating lunch being fed by Staff B meanwhile, Resident # 93 was observed with no food. The surveyor asked Staff B where Resident #93's food was. Staff B reported it will be coming soon. During an interview on 01/08/24 at 12:17 PM Staff B was asked about standing while feeding the resident. Staff B stated, I am sorry but there is only one chair in the room, and it has stuff on it. Staff B acknowledged that she should not be standing and feeding the resident. On 01/08/24 at 12:23 PM Resident #93's lunch tray arrived in the room and Staff B set up the food tray and sat in a chair to feed the resident. On 01/10/24 at 09:37 AM, the Assistant Director of Nursing (ADON) stated I will be conducting an in-service for all nursing staff regarding dignity-making sure they sit when they are feeding the residents, and all other dignity concerns. Review of the facility's policy titled Assistance with Meals revision date January 2023 states: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example a. Not standing over residents while assisting them with meals. Page 1 of 14 106100 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide reasonable accommodations for Resident #343 as evidenced by Resident #343 call light was out of reach and had difficulty using other devices. There were 143 residents residing in the facility at the time of the survey. Residents Affected - Few Findings include: On 01/08/24 at 10:31 AM. In an interview with Resident #343. Resident #343 stated, I'm not able to use the call light to ask for help. I'm not able to move my fingers to touch the device. On 01/10/24 at 02:50 PM, during an observation and interview with Resident #343. It was observed that the thumb call light was tucked underneath Resident #343's pillow to the right side of the resident's head. The resident was holding the bed control keypad on his chest. The resident was asked: Are you able to use your call light, if not, how are you able to call staff for assistance? Resident #343 stated, I'm hard of hearing. The call light is too hard to push. It's very difficult. The bed control is hard to push the buttons. My fingers are weak. The resident further reported that he cannot raise the television volume nor turn the light on or off. On 01/10/24 at 2:58 PM, during an interview Staff C a Registered Nurse (RN) was asked, if Resident #343 able to use the call light and how does Resident #343 call for help from staff and where are staff required to place call lights for residents? Staff C reported that Resident #343 cannot move their hands. The left hand is more contracted, and the right hand is swollen. I placed the call light on his chest, but the resident was not able to use the bed control. He uses his voice too. When residents are alert and oriented, the call lights are to be on the bed and where the resident can reach it. On 01/10/24 at 03:11 PM; In an interview with Staff D an Occupational Therapist (OT) and Staff E a Physical Therapist (PT), was asked, how Resident #343 was doing in occupational therapy and based on the current assessment is Resident #343 able to use a thumb call light. Staff D stated, I performed this assessment. The last day of physical and occupational therapy was on December 1, 2023. On both arms there were some limitations and impairment. We did not test his right- and left-hand grip as we do not have the machine for that. The resident's strength can decrease over time. He won't be able to use a pancake call light and thumb call light. It would require more effort. One of my goals was to use the pancake call button but he didn't have the strength and the manual dexterity. Staff further reported that Resident #343 was placed across from the nursing station and is able to communicate his needs. Review of facility documentation titled Occupational evaluation and plan of treatment revealed. In the section titled Objective Progress and Short-Long term goals. The short-term goal for Resident #343 documented that the resident will exhibit improved right manual dexterity as evidenced by an increased ability to press the pancake nurse call button in three out of five trials. Target date 11/2/23. The long-term goal stated Resident #343 will exhibit improved right manual dexterity as evidenced by an increased ability to press the call button five out of five times. Target date 12/1/23. In the section titled Musculoskeletal System Assessment indicated: Out of a scale of five. Resident's right shoulder flexion and extension was a two plus. The left shoulder flexion and extension was a one. The right elbow and wrist strength were two plus. The left elbow and wrist strength was one. The left-hand and right-hand grip was not tested. 106100 Page 2 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0558 Level of Harm - Minimal harm or potential for actual harm On 01/11/24 at 9:24 AM. In an observation and interview with Resident #343. It was observed that the call light device was changed to a pancake call light. Resident # 343 was asked if he was able to press the call light and Resident #343 pressed the pancake call light, and the call light rang in the room. The resident was asked if it was better for him to use this type of call light to work better for him. Resident #343 stated This is much better. My luck because you are here. Residents Affected - Few On 01/11/24 at 10:35 AM, the Director of Nursing (DON) was asked where staff are to place call lights for a resident and Resident #343's history with using the thumb call light. The DON was also asked if the facility has any other types of call lights available for ease of use. The DON stated, Call lights are to be within reach of the resident. I spoke to [Resident #343] yesterday. With the previous call light, he was able to hold the call light with one hand and use the other hand to press the button. We wondered if he had the strength to use the call light. With him, it's difficult to press it. Sometimes, he was able to use the thumb call light. We tried the pneumatic call light before. We will try the pancake call light and monitor that. We have pneumatic call lights, but we were concerned that they would create a fire. We placed the resident close to the nursing station. Staff are aware to check on [Resident #343] frequently. It is not uncommon for residents who are unable to use the call light. He could press the call light, but it was difficult. On 1/11/24 at 11:33 AM. In an interview the Director of Maintenance was asked what type of call lights are available in the facility and if any pancake call lights were available. The Director of Maintenance stated: We have thumb and pneumatic call lights. We do not have pancake call lights. If I need another type of call light, I can contact Central Supply. Review of Resident #343 clinical records revealed a medical diagnosis of muscle weakness and lack of coordination. Record review of Resident #343's physician orders dated 12/5/23 at 3:13 PM revealed passive range of motion exercises to bilateral lower extremities and upper extremities in all available planes with the patient supine in bed to maintain joint/skin integrity. Three times a week and as tolerated. Record review of Resident #343's Minimum Data Set, dated [DATE] revealed in section C: Cognitive Patterns a brief interview of mental status score was a six suggesting severe cognitive impairment. In section GG: Functional Abilities and Goals, Resident #343 needed partial assistance from another person to complete any activities. Upper extremities were impaired on both sides. Eating was dependent with partial/ moderate assistance. In section O: Special Treatments, Procedures, and Program. Occupation therapy and physical therapy started on 11/2/23 and had four days in the last seven days. Review of Resident #343's care plan with next review date of 3/20/2024 revealed: The resident had a history of arthritis and has a risk for injury or discomfort. The intervention was for the use of supportive devices such as splints, etc. as recommended by the occupational therapist. The resident is dependent on staff for emotional, intellectual, physical, and social stimulation related to cognitive deficits, and physical limitation. Interventions were to assist/ escort to activity functions as needed. Focus stated resident is a risk for falls related to muscle weakness and other lack of coordination. The intervention was to keep the call light within reach. Focus stated the resident has impaired functional abilities due to weakness, pressure ulcers, and impaired mental status. Interventions were to assist with activities of daily living based on the resident's functionality to keep residents clean and well-groomed. Review of the facility's policies and procedures titled Accommodation of Needs last reviewed 106100 Page 3 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few January 2024 Policy statement indicate: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. In the section titled, Policy Interpretation and Implementation. Part one, the resident individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or the residents would be endangered. Part two, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. Part 4. To accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the resident's wishes. For example, interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communications, and maintain dignity. 106100 Page 4 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, homelike environment and comfortable interior for 1 out of 3 residential floors (Resident rooms on 300 floor North Unit). The Findings Included: During the initial observations on 01/08/2024 beginning at 08:41AM of residents and residents' rooms revealed: room [ROOM NUMBER]B was noted with water stains on the wall and roof by the window (B Bed), (Photo Available). Rooms 307A, 308, 311B, 314B-Garbage on the floors-Straw wrapping, empty condiment packets, tissues, alcohol pad packets, and paper of different kinds (photo available). room [ROOM NUMBER] B-Privacy curtain observed with dark red stains (Photo available) During an interview on 01/08/24 at 09:22 Resident #92 reported that when it rains, water leaks through the wall in her room (Photo available). The resident stated she has respiratory issues, every time it rains the situation gets worse, you can see more water spots on the wall when it rains. The people here know all about the problem and it has been going on for some time, a long time now. In an interview on 01/10/24 at 09:02 AM, the Maintenance Director/Housekeeping/Laundry stated: Last time we had a problem with the air conditioning (AC), the AC had a leak, and it goes through the wall, the AC was fixed last week, and now we will prepare the wall. We saw the problem with the wall, but we were working on finding out where the leak was coming from before, we did any repairs to the wall. We finally figured out that the leak was coming from the AC. We removed the AC and saw there was a hole, and we fixed the hole. So now we are waiting for the drywall to dry, and then we will plaster and paint the wall in room [ROOM NUMBER]. The whole process of finding out where the leak was coming from took about 2 to 3 weeks. I personally spoke to the resident in 305B to let her know what was going on with the wall in the room. I do not have any invoices for the repairs because I fixed the hole myself. Regarding cleaning the residents' rooms, Housekeeping cannot go into the rooms to clean during breakfast, lunch, or dinner. Once the resident starts being served their food, we stop cleaning the rooms and wait until the residents are done eating. We have one porter/housekeeper that works 12:00 PM to 8:30 PM at night for cleaning. The morning shift Porters starts at 6:00 AM and Housekeeping starts at 7:00 AM. Interview with Resident #92 on 01/11/24 at 08:49 AM revealed the first time she noticed the leak to the wall was a more than a few months ago, she had her son talk to someone at the facility, they came and looked at the wall and said they fixed the problem, the problem was never fixed, and no one has given her an update about what is going on. Review of the facility's policy titled Cleaning and Disinfecting Resident's Rooms revision date 106100 Page 5 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0584 Level of Harm - Minimal harm or potential for actual harm January 2023 indicated: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Residents Affected - Few 4. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. 106100 Page 6 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 139) out of one resident whose MDS assessments reviewed at the time of survey. This deficiency has the potential to affect 143 residents residing in the facility at the time of survey. Residents Affected - Few The findings included: Record Review of admission Record revealed Resident # 139 was admitted to the facility on [DATE] and discharged on 10/13/2023. Record review of the clinical records revealed the resident's diagnosis included, but were not limited to, traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, unspecified focal traumatic brain injury without loss of consciousness, subsequent encounter, other lack of coordination, difficulty in walking, not elsewhere classified, dysphagia, oropharyngeal phase, muscle weakness (generalized), generalized anxiety disorder, gastro-esophageal reflux disease with esophagitis, without bleeding, anemia, unspecified, unspecified psychosis not due to a substance or known, physiological condition, primary open-angle glaucoma, right eye, stage unspecified, essential (primary) hypertension, constipation, unspecified, benign prostatic hyperplasia without lower urinary tract, symptoms, repeated falls, fall on same level from slipping, tripping and stumbling with subsequent striking against other object, subsequent encounter. Record review of Discharge - Return not Anticipated Minimum Data Set (MDS) dated [DATE] revealed the resident was discharged to short-term/general hospital. Record review of the Care Plan: Date Initiated: 09/22/2023, Revision on: 12/28/2023 revealed Focus: Resident is admitted as short-term placement and will go home with son upon Discharge. Goals: Resident will have discharge planning initiated. Interventions: Arrange for transportation. Discuss discharge plan with resident/responsible party. Involve family or significant others in all teaching, evaluate equipment needs and order accordingly. Nurse's note dated 10/13/2023 time stamped 13:15 documented resident discharged home today with home health care services Physical Therapy (PT), Occupational Therapy (OT) nurse aid and RN, and Durable Medical Equipment (DME) supplies necessary to promote and support Activities of Daily Living (ADLS). At this time the resident was hemodynamically stable within his baseline status, with no complaints of pain or discomfort, or any sign of distress. Skin dry and warm to touch, no rash no bruising, no redness or trauma, no open area noted. Instruction was given to the patient to follow up with Primary Care Physician (PCP) within a week for continuation of services including medical regimen and two schedule appointment . with Cardiology other with Neurology, The patient was educated on sign or symptoms of distress or complication of existing condition that that granted emergency medical attention before next PCP consult. I ordered and reported any sign or symptoms to avoid further complication, resident verbalized understood. All resident belongings are given to resident facility transportation in place. During an Interview on 01/11/24 at 10:53 AM the MDS Coordinator was asked about the MDS coding on Section A that indicated that the resident had gone to the hospital but documented in the progress notes that the resident was discharged from home. The MDS Coordinator stated: Let me check. When he checked he stated: You are correct I need to correct it, because resident actually went to the 106100 Page 7 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0641 community/home and not to a hospital. Level of Harm - Minimal harm or potential for actual harm Record review revealed the Nursing Home Transfer and Discharge Notice was completed on 10/13/2023 and indicated: Location to which resident is transferred or discharged to Home. Residents Affected - Few Review of the facility's MDS Policy and Procedure documented: Policy Statement The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established process for completing, submitting, and making corrections to MDS. Completion of MDS Interdisciplinary Team will complete sections on MDS for a resident in the facility. Submission of MDS The assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. Correction of Error If an error is discovered in a record that has already been accepted by QIES ASAP system, implement procedures for either Modification or Inactivation of the information in the system within 14 days of the discovery of the error. 106100 Page 8 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

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** Resident # 46 Residents Affected - Few Observation of Resident # 46 on 01/08/24 at 09:18 AM revealed the resident lying on his bed, awake watching television. Resident was receiving oxygen therapy. It was observed the oxygen concentrator level set at 4 LPM. (Photographic evidence). No distress or anxiety was noted. A sign Oxygen in use was observed at the room door. Observation of Resident # 46 on 01/09/24 at 07:57 AM. The resident was observed sleeping. No distress or anxiety was noted. The oxygen concentrator level was set at 4 LPM (Photographic evidence). Observation of Resident # 46 on 01/10/24 07:48 AM. The resident was sleeping. No distress or anxiety was noted. The oxygen concentrator level was set at 4 LPM. (Photographic evidence). Record review of admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnosis included, but were not limited to, Rheumatoid arthritis, unspecified, respiratory failure, unspecified with hypoxia, interstitial pulmonary disease, unspecified, disorder involving the immune mechanism, unspecified, chronic obstructive pulmonary disease, unspecified, cutaneous abscess, unspecified, other lack of coordination, difficulty in walking, not elsewhere classified, muscle weakness (generalized), unspecified protein-calorie malnutrition, chronic kidney disease, stage 3 unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified osteoarthritis, unspecified site, rash and other nonspecific skin eruption, hypo-osmolality and hyponatremia, pain, unspecified, encounter for screening for respiratory tuberculosis, generalized anxiety disorder, orthostatic hypotension, hypothyroidism, unspecified, other disorders of electrolyte and fluid balance, not elsewhere, classified, major depressive disorder, recurrent, unspecified, insomnia, unspecified, essential (primary) hypertension, chronic rhinitis, gastro-esophageal reflux disease without esophagitis, long term (current) use of antithrombotic/antiplatelets. Record review of orders dated 01/10/2024 revealed the resident had an order of Oxygen Therapy at 2 LPM via nasal cannula continuously. Record review of Quarterly Minimum Data Set (MDS) Section C dated 11/07/2023 revealed the resident Brief Interview for Mental Status (BIMS) Summary Score was 13. Record review of Quarterly MDS Section GG dated 11/07/2023 revealed the resident Functional Abilities and Goals - Walker-Yes, Upper extremity (shoulder, elbow, wrist, hand)- Impairment in both sides, Eating-Setup or clean up assistance, Toileting hygiene, Sit to stand, Toilet transfer-Substantial/maximal assistance. Record review of Quarterly MDS Section O dated 11/07/2023 revealed the resident was receiving oxygen therapy continuous. Record review of Care Plan initiated on 10/19/2023 and completed on 01/25/2024 revealed the Focus: Resident is using Oxygen therapy. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions: Administer oxygen as per MD orders. Monitor for signs/symptoms of respiratory distress and report to MD PRN (as needed) such as increased respirations, 106100 Page 9 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and/or skin color changes. (e.g., respiratory treatment and care, possible complications, communication, advance directives, equipment functioning and cleaning, procedures for emergencies). Interview with Staff A Registered Nurse (RN) on 01/10/24 at 08:37 AM stated I do not know about this resident, I just started working today and I have not checked her, we are very good following the doctors' orders. Let me check and if it says different, I will correct it immediately. Based on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for two Residents (#69 #46,) out of 28 sampled residents. As evidenced by several observations of Resident #46 revealed the oxygen was running at the incorrect rate. Resident #69's tracheostomy (trach) collar that provided oxygenation to the resident was dislodged from the trach opening and hanging to the right side of the resident's neck. There were 14 residents that required respiratory services out of the 148 residents residing in the facility at the time of the survey. The Findings Included: During observation on 01/08/24 at 09:43 AM Resident #69 was in bed Oxygen (02) running at 10 liters per Minute (LPM) via trach collar, the resident was not receiving oxygenation via trach collar because the trach collar for oxygenation was off of the resident and laying on the right side of resident's neck. On 01/08/24 09:49 AM Registered Nurse (Staff C) and the surveyor went to Resident #69's room, Staff C stated the resident removed the 02 tubing herself, Staff C donned gloves, placed the trach collar for oxygenation correctly on resident, and elevated the head of the bed. When asked by the surveyor how often does she checks on the resident, Staff C stated: I check on the resident every time I make my rounds, which is usually every hour. On 01/09/24 at 09:16 AM Resident #69 was not in the room. The bed was stripped of linen. The Assistant Director of Nursing (ADON) reported that the resident was sent to the hospice unit yesterday. Review of the medical records for Resident #69 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Respiratory Failure, unspecified, unspecified whether with hypoxia or hypercapnia and Encounter for attention to tracheostomy. Resident #69 was discharged on 01/08/2024 to a hospice unit. Review of the Physician's Orders Sheet for January 2024 revealed Resident #69 had orders that included but not limited to: Trach: Encourage and assist Resident with use of humidified Oxygen 10 LPM via trach collar continuously. Trach: Obtain O2 saturations-every shift. Notify physician if saturations less than 90%. Trach: #6.5 millimeter (mm) for Diagnosis: encounter for tracheostomy care. Suction tracheostomy tube-every shift for patency or to keep the airway open related to respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia and as needed for patency or to keep the airway open. Record review of Resident #69's 02 (oxygen) saturation recordings on 1/8/23 ranged from 92% to 98% via oxygen by trach collar at 10 LPM. 106100 Page 10 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0695 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #69 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed in Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is undetermined. Section GG for functional Abilities and Goals documented resident is dependent for care. Section J for Health Conditions documented no shortness of breath Section O for Special Treatments documented resident received oxygen therapy, tracheostomy care and suctioning. Residents Affected - Few Record review of Resident #69 's Care Plans reference Date 01/17/2024 revealed: Resident requires Tracheostomy due to inability to maintain airway related to Respiratory failure. Interventions include Labs and x-rays as ordered and notify MD of any abnormalities. Maintain aspiration precaution. Monitor for congestion and suction as needed. Monitor for elevated temperature and notify MD as needed. Monitor for signs and symptoms of respiratory distress such as shortness of breath, cyanosis, and wheezing. Report to MD promptly. Monitor O2 sat as ordered and as needed. Provide Oral Care as needed to maintain oral cavity clean, and Provide Tracheostomy Care as indicated. Resident is at risk for shortness of breath, impaired breathing pattern secondary to diagnosis of respiratory failure. Interventions In room visits for social stimulation if resident cannot attend activities. Monitor for episodes of shortness of breath and implement interventions as ordered, notify Physician (MD) if ineffective and follow up as indicated. Oxygen per MD order. Provide reassurance and support to prevent anxiety during episode of shortness of breath and Provide rest periods in between activities as needed. Review of the nursing progress notes for Resident #69 dated 1/8/2024 timestamped 18:46 documented Resident is transfer at this time to Hospice unit. family member aware. During an interview on 01/10/24 at 09:32 AM the Assistant Director of Nursing (ADON) stated: The nurses are required to conduct their rounds hourly but for this resident moving forward when and if she comes back to the facility, we will be doing rounds more often for the resident. The nurse told me that the resident most likely had removed her oxygen, regarding if that is something the resident did regularly, I would have to follow up with my nurses. Review of the facility's Policy and procedure for Oxygen Administration Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. 3. Assemble the equipment and supplies as needed. Physician Orders Policy and procedure Policy Statement 106100 Page 11 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0695 Level of Harm - Minimal harm or potential for actual harm Orders for medications and treatments will be consistent with principles of safe and effective order writing. Nursing Staff must follow safe and effective transcription of physician orders and safe and effective medication/treatment administration. Residents Affected - Few 106100 Page 12 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food under sanitary condition by ensuring the ice cream freezer was properly defrosted and did not contain a buildup of ice. This has the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Refrigerators and Freezers Policy and Procedure (revision date May 2023); Policy Statement-This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation; Policy Interpretation and Implementation-7) Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, excess condensation and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance and or cleaning schedules will be monitored for compliance. Observation of the initial kitchen tour on 1/08/24 at 8:31 AM with the Certified Dietary Manager revealed the ice cream freezer noted with a thick buildup of ice within the inside parameter of the unit. Photographic evidence provided. The facility was cited in November 2022 for the ice buildup in the ice cream freezer. Interview with the Certified Dietary Manager on 1/08/24 at 8:32 AM. He stated, This should not be here and we will defrost it right now. Interview with the Certified Dietary Manager on 1/10/24 at 8:45 AM. He stated, The ice cream freezer is defrosted and cleaned every Monday. I had to defrost it again today. Review of the Dietary Weekly Cleaning Schedule dated 12/10/23-1/07/24 documented the ice cream freezer was defrosted and cleaned every Monday. 106100 Page 13 of 14 106100 01/11/2024 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

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 record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to resident rights, safe, clean, comfortable and homelike environment and food procurement, store, prepare and serve-sanitary resulting in repeated deficient practice. The facility was cited for Resident rights in 2022; Safe, clean, comfortable and homelike environment in 2022 and Food procurement, store, prepare and serve-Sanitary in 2022. These repeated deficiencies practice has the potential to affect any of the 143 residents residing in the facility. The findings included: Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Policy and Procedure (implemented November 2017, reviewed March 2023) documented the following: Policy-It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2) The QAA Committee shall be interdisciplinary and meet alongside Risk Management Committee: a) Consist at a minimum of: The Director of Nursing Services, The Medical Director and at least three other members of the facility's staff; b) Meet a least quarterly and as needed to coordinate and evaluate activities under the QAPI Program and c) Develop and implement appropriate plans of action to correct identified quality deficiencies. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 10/26/23 for September 2023, 11/30/23 for October 2023 and 12/21/23 for November: documented the facility had a QAA Committee meeting quarterly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. On 1/11/24 at 12:53 PM, interview with the Administrator/QAA. He stated, The QAA Committee meets quarterly and monthly. We meet the last Thursday of the month. Committee members are: Administrator, DON, Medical Director and Department Heads. The purpose of the QAA committee is to identify any trends regarding quality of care and any physical plant concerns. 106100 Page 14 of 14