Health inspection·February 17, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview with the Director of Nursing/Abuse Coordinator/Risk Manager on 2/17/25 at 11:25 AM. He stated, She did not have a fall. She hit her head with the wheelchair. The CNA was trying to transfer her from the bed to the wheelchair. She pulled the wheelchair closer to the bed and she let the resident go while she was sitting on the edge of the bed. The bruises did not come right away. At the moment, she didn't have a bruise. The incident was on 2/01/25, the bruises were noticed on 2/03/25. When the incident happened, she didn't have any bruises, the bruises were noted on 2/03/25. The family came and saw the patient and asked the nurse and she hadn't noticed the bruises. The CNA did not notify the facility about the incident on 2/01/25 and she was supposed to. She was reprimanded for not telling anyone about the incident. She did not have a fall. She hit her head on the handrest of the wheelchair. We did an incident report. The doctor was notified, an order was given for x-rays of the sacrum and coccyx. There were no fractures. Interview with Staff A, CNA on 2/17/25 at 12:52 PM via Spanish translator. She revealed on 2/01/25, she bathed the resident, dressed her and she was going to transfer her to the wheelchair. She had her on the edge of the bed, she held her with one hand and held the wheelchair with the other. The resident lost control of her body and leaned forward, and she bumped her head on the wheelchair handrest. The correct way to transfer a resident from the bed to the wheelchair is that you grab the resident, have them stand and then turn them. She confirmed that the wheelchair was not positioned before transferring the resident. She checked her and she didn't see anything and didn't think she had to report it. She was supposed to report the incident to the nurse but did not. Interview with Staff B, Registered Nurse (RN) on 2/17/25 at 1:19 PM. She stated, I work from 7:00 AM to 7:00 PM and during the day skilled nursing was done. The resident had no complaints of pain. After dinner, the daughter visited and asked me about something on her head. Throughout the day I never saw anything on her head. When I looked on the left side of her head under the hair, I saw the bruising. I did not see any bruise on her hand. I made an assessment head to toe. Her vital signs were stable and no complaint of pain. I called the DON/Abuse Coordinator and reported the bruise on 2/03/25. I called the doctor, and he gave an order for an x-ray. The x-ray was negative. I endorsed it to the night shift for neuro checks. The CNA is supposed to tell the nurse when something happens and if they hit their head. Record review of the Accidents and Incidents-Investigating and Reporting Policy and Procedure (revision date July 2017, reviewed January 2025); Policy Statement-All accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator; Policy Interpretation and Interpretation -2h) The date/time the injured person's family was notified and by whom. Page 1 of 4 106100 106100 02/17/2025 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on records reviewed and interviews the facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury which required medical attention for one resident (Resident #1) out of four sampled residents, as evidenced by during assisted transfer Resident#1 hit her head on the wheelchair and the incident went unreported after bruising was identified and reported the family member to staff. There were 143 residents residing in the facility at the time of the survey. The findings included: On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a small scratch on the left leg. Record review of a demographic sheet for Resident#1 revealed an initial admission date of 12/15/21 and readmission date of 8/8/24 with diagnosis that included: Dementia and Unspecified fall. Record review of an Annual Minimum Data Set reference dated 12/27/24 revealed Resident#1 is moderately impaired cognitively, required substantial/maximal assistance for chair/bed-to-chair transfer and had no falls since admission/entry or reentry or the prior assessment. Further review of a care plan initiated on 12/15/21 and revised on 10/15/24 revealed Resident#1 is at risk for falls related to muscle weakness, impaired mobility and had a fall that occurred on 4/1/24, had goals to have no episodes of falls and suffer no injuries from falls. The interventions included: Encourage resident to ask for assistance when attempting to transfer. Review of a physician's order sheet revealed orders dated 11/24/24 for fall precaution every shift and order dated 8/8/24 for bed in lowest position every day and night shift. Review of progress notes revealed no documentation related to the incident that occurred during the resident's transfer. Record review of a Fall Risk assessment dated [DATE] revealed Resident#1 was at a low risk for falls. Review of a skin check dated 2/1/25 revealed Resident #1's skin was intact with no redness or bruising noted. On 2/17/25 at 11:35 AM, the Director of Nursing (DON) stated, After witnessing or discovering that a resident had a fall or injury of unknown origin, the protocol is for the staff to report to the doctor and family, we do an incident report and staff should document. Staff monitor residents to prevent fall depending on their risk for example by taking residents to activities. [Resident#1] hit her head on the arm rest of the wheelchair during transfer because the Certified Nursing Assistant was not looking or holding the resident for a moment. [Resident #1] was listed on the Incident Log for 2/1/25 after The CNA reported to us on 2/3/25 that the resident hit her head on the wheelchair during transfer. When an incident report is completed, it triggers for other assessments. The Skin check is dated 2/1/25 because the incident happened on that date, but I completed the Skin check for the Resident on 2/3/25. 106100 Page 2 of 4 106100 02/17/2025 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview with the Director of Nursing/Abuse Coordinator/Risk Manager on 2/17/25 at 11:25 AM. He stated, She did not have a fall. She hit her head with the wheelchair. The CNA was trying to transfer her from the bed to the wheelchair. She pulled the wheelchair closer to the bed and she let the resident go while she was sitting on the edge of the bed. The bruises did not come right away. At the moment, she didn't have a bruise. The incident was on 2/01/25, the bruises were noticed on 2/03/25. When the incident happened, she didn't have any bruises, the bruises were noted on 2/03/25. The family came and saw the patient and asked the nurse and she hadn't noticed the bruises. The CNA did not notify the facility about the incident on 2/01/25 and she was supposed to. She was reprimanded for not telling anyone about the incident. She did not have a fall. She hit her head on the handrest of the wheelchair. We did an incident report. The doctor was notified, an order was given for x-rays of the sacrum and coccyx. There were no fractures. Interview with Staff A, CNA on 2/17/25 at 12:52 PM via Spanish translator. She revealed on 2/01/25, she bathed the resident, dressed her and she was going to transfer her to the wheelchair. She had her on the edge of the bed, she held her with one hand and held the wheelchair with the other. The resident lost control of her body and leaned forward, and she bumped her head on the wheelchair handrest. The correct way to transfer a resident from the bed to the wheelchair is that you grab the resident, have them stand and then turn them. She confirmed that the wheelchair was not positioned before transferring the resident. She checked her and she didn't see anything and didn't think she had to report it. She was supposed to report the incident to the nurse but did not. Interview with Staff B, Registered Nurse (RN) on 2/17/25 at 1:19 PM. She stated, I work from 7:00 AM to 7:00 PM and during the day skilled nursing was done. The resident had no complaints of pain. After dinner, the daughter visited and asked me about something on her head. Throughout the day I never saw anything on her head. When I looked on the left side of her head under the hair, I saw the bruising. I did not see any bruise on her hand. I made an assessment head to toe. Her vital signs were stable and no complaint of pain. I called the DON/Abuse Coordinator and reported the bruise on 2/03/25. I called the doctor, and he gave an order for an x-ray. The x-ray was negative. I endorsed it to the night shift for neuro checks. The CNA is supposed to tell the nurse when something happens and if they hit their head. Record review of the Accidents and Incidents-Investigating and Reporting Policy and Procedure (revision date July 2017, reviewed January 2025); Policy Statement-All accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator; Policy Interpretation -2h) The date/time the injured person's family was notified and by whom. Based on interviews and record reviews, the facility failed to ensure one resident (Resident #1) out of four sampled residents received adequate supervision to prevent accidents as evidenced by during transfer, Resident #1 sustained injuries that were not reported immediately by staff and were discovered by a family member. The findings included: On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when 106100 Page 3 of 4 106100 02/17/2025 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0689 Level of Harm - Minimal harm or potential for actual harm greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a small scratch on the left leg. Record review of a demographic sheet for Resident#1 revealed an initial admission date of 12/15/21 and readmission date of 8/8/24 with diagnosis that included: Dementia and Unspecified fall. Residents Affected - Few Record review of an Annual Minimum Data Set reference dated 12/27/24 revealed Resident#1 is moderately impaired cognitively, required substantial/maximal assistance for chair/bed-to-chair transfer and had no falls since admission/entry or reentry or the prior assessment. Further review of a care plan initiated on 12/15/21 and revised on 10/15/24 revealed Resident#1 is at risk for falls related to muscle weakness, impaired mobility and had a fall that occurred on 4/1/24, had goals to have no episodes of falls and suffer no injuries from falls. The interventions included: Encourage resident to ask for assistance when attempting to transfer. Review of a physician's order sheet revealed orders dated 11/24/24 for fall precaution every shift and order dated 8/8/24 for bed in lowest position every day and night shift. Review of progress notes revealed no documentation related to the incident that occurred during the resident's transfer. Record review of a Fall Risk assessment dated [DATE] revealed Resident#1 was at a low risk for falls. Review of a skin check dated 2/1/25 revealed Resident #1's skin was intact with no redness or bruising noted. On 2/17/25 at 11:35 AM, the Director of Nursing (DON) stated, After witnessing or discovering that a resident had a fall or injury of unknown origin, the protocol is for the staff to report to the doctor and family, we do an incident report and staff should document. Staff monitor residents to prevent fall depending on their risk for example by taking residents to activities. [Resident#1] hit her head on the arm rest of the wheelchair during transfer because the Certified Nursing Assistant was not looking or holding the resident for a moment. [Resident #1] was listed on the Incident Log for 2/1/25 after The CNA reported to us on 2/3/25 that the resident hit her head on the wheelchair during transfer. When an incident report is completed, it triggers for other assessments. The Skin check is dated 2/1/25 because the incident happened on that date, but I completed the Skin check for the Resident on 2/3/25. 106100 Page 4 of 4