Health inspection·May 22, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to secure confidential information for the residents on the fourth floor as evidenced by an observation of an unattended paperwork with residents' pictures, names and rooms left visible on top of the fourth floor's south medication cart. There were 24 residents residing on the fourth floor. Residents Affected - Few The findings included: Observation on 5/19/25 at 6:40 AM revealed confidential paperwork with residents' names, corresponding pictures and room numbers were observed on top of the unattended fourth floor's south medication cart. During an interview on 5/19/25 at 6:55 AM, Staff A, Registered Nurse (RN) stated: Sorry, I left the paperwork on top of the medication cart; I know all information should be kept private. Interview on 5/21/25 at 1:17 PM, the Director of Nursing (DON) stated: All resident information should be kept confidential. Record review of a policy titled Protected Health Information (PHI), Safeguarding Electronic revised January 2024, Reviewed January 2025 revealed Policy: Electronic protected health information (e-PHI) is safeguarded by administrative, technical and physical means to prevent unauthorized access to protected health information. Policy Interpretation and Implementation: 1. This facility ensures the confidentiality, integrity and availability of all e-PHI created, maintained, received, or transmitted by our information system. Page 1 of 6 106100 106100 05/22/2025 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, record reviews and interviews, the facility failed to update a respiratory care plan for one (Resident #79) out of one sampled resident as evidenced by a respiratory care plan with interventions for a Bilevel Positive Airway Pressure (BiPAP) machine, despite physician orders for the discontinuation of the BiPAP machine since 10/15/24. There were three residents with BiPAP machines in the facility at the time of survey. The findings included: On 5/19/25 at 6:52 AM Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer (photographic evidence). On 5/20/25 at 9:26 Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer. On 5/22/25 at 7:26 AM Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer. Record review of Resident #79's demographic sheet revealed an admission date of 8/30/23 with diagnosis that included: Heart Failure and Insomnia. Record review of a Quarterly Minimum Data Set (MDS) reference dated 4/8/2025 revealed Resident #79's was severely impaired cognitively, was independent with eating. Further review revealed Resident #79 had no shortness of breath and did not receive oxygen or respiratory therapy. Record review of the electronic health record revealed Resident #79 had a Respiratory care plan that was updated on 11/21/23 for sleep Apnea BiPAP to be applied at bedtime. Record review of Resident #79's Physician's Order Sheet revealed no active orders for a BiPAP machine. Further review revealed orders dated 8/30/23 for BiPAP to be applied at bedtime (HS) and may wear as needed (PRN) and may remove at liberty every night shift related to Obstructive Sleep Apnea. Review of the October 2024 physician orders revealed an order dated 10/15/24 for the BiPAP to be discontinued. On 5/22/25 at 7:10 AM, during a side-by-side observation with the night supervisor in Resident # 79's room; the night supervisor was asked if Resident # 79 uses the BiPAP machine; the night shift Supervisor stated: It is put on at nighttime and removed when the resident first wakes up. The surveyor requested to view the mask. The night shift supervisor opened the drawer, and a mask was observed inside a plastic bag (photographic evidence). Interview on 5/22/25 at 7:35 AM, the night shift supervisor stated, I checked and there are no active physician orders for this resident to receive the BiPAP machine, so the nurse did not administer it. On 5/22/25 at 8:40 AM, the MDS coordinator was asked about the interventions for the BiPAP machine mentioned in the care. The MDS coordinator stated: I will check. 106100 Page 2 of 6 106100 05/22/2025 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/22/25 at 9:05 AM, the MDS coordinator returned with a care plan that documented the BiPAP interventions were resolved on 5/20/25. The MDS coordinator was asked about the time frame for resolving care plans once the orders have been discontinued. The MDS Coordinator stated, I think someone was trying to update the information. Interview on 5/22/25 at 9:38 AM, the Director of Nursing (DON) when asked about care plan interventions the DON stated: This resident (Resident # 79) had a physician order for use of BiPAP that were discontinued for a while, the machine is still in the room because the son lives out of the country and left it and staff should not be administering the BiPAP machine without an order. Record review of a policy titled Care Plans, Comprehensive Person-Centered revised January 2025 revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes. 106100 Page 3 of 6 106100 05/22/2025 University Health and Rehabilitation Center 724 NW 19th St Miami, FL 33136

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews and record reviews, the facility failed to properly secure medications for residents residing on the fourth floor, as evidenced by a plastic bag with medications observed on top of the unattended fourth floor's south medication cart. There were 24 residents residing on the fourth floor at the time of survey. The findings included: Observation on 05/20/25 at 9:15 AM, revealed a plastic bag filled with medications left unattended on top of the south medication cart (photographic evidence). On 05/20/25 at 9:15 AM, Staff A, Registered Nurse (RN) who was seated at the nursing station was asked if medications were inside the plastic bag on top of the south medication cart. Staff A, RN walked with the surveyor to the medication cart, opened the plastic bag and revealed the contents which included loose pills and pills in containers. Staff A, RN stated:I found these medications in a resident's room, removed it and was going to notify the supervisor when I was called to help another nurse with an emergency situation. On 05/20/25 at 9:25 AM, Staff A, RN revealed: Any medications found in residents' rooms should be given to the supervisor .I should have taken the medication off the cart. On 05/21/25 at 1:15 PM, the Director of Nursing (DON) stated, Medications are to be kept in a locked cart. If a nurse discovers medication in a resident's room the medications are to be secured and labeled until the family can pick it up. Record review of a Policy titled, Storage of Medications Revised April 2019, Reviewed January 2025 Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 106100 Page 4 of 6 106100 05/22/2025 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 - Many 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 conditions as evidenced by the walk-in refrigerator contained flower bouquets on the shelves among the fruits and vegetables. This has the potential to affect 128 out of 133 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Food Storage Policy and Procedure (review date November 2024); Policy-Food storage areas are maintained in a clean, safe and sanitary manner and maximize nutrient retention and food quality; Procedure-1) Perishable foods are stored immediately after delivery. Observation of the initial kitchen tour on 5/19/25 at 6:47 AM with the Dietary Supervisor and Corporate CDM (Certified Dietary Manager) revealed the walk-in refrigerator with four bouquets of flowers lying on the shelf with vegetables and fruits. Photographic evidence submitted. Interview with the Corporate CDM on 5/19/25 at 6:48 AM. He revealed that the bouquets of flowers were for Nurses' week. He confirmed that the bouquets of flowers should not be in the walk-in refrigerator. Interview with the Dietary Supervisor on 5/19/25 at 6:50 AM. She revealed that the flowers were not to be in the walk-in refrigerator. 106100 Page 5 of 6 106100 05/22/2025 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 observations, interviews and record review, the facility failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F812- Food Procurement, Store/Prepare/Serve - Sanitary and F867- Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA). These repeated deficient practices have the potential to affect all residents residing in the facility. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 01/11/ 2024,

F812 Food Procurement, Store/Prepare/Serve/ Sanitary was cited related the facility's failure to store food under sanitary conditions related to a buildup of ice in the ice cream freezer with the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of that survey. During this survey with an exit dated 05/22/2025, repeated deficient practice was identified for F812-Food Procurement, Store/Prepare/Serve/Sanitary, related to the walk-in refrigerator containing flower bouquets on the shelves among the fruits and vegetables which has the potential to affect 128 out of 133 residents who eat orally residing in the facility at the time of this survey. F867-Quality Assurance and Performance Improvement was cited due to the QAPI/QAA committee's failure to monitor previous problem areas identified with existing need for improvement based on the committee's continued evaluation of their performance improvement projects. Interview with the Administrator, and Director of Nursing (DON) on 05/22/2025 at 12:10 PM, revealed The QAPI committee meets monthly on the fourth Thursday of each month. The most recent meeting was held on April 24, 2025. The committee includes: the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Registered Dietitian, Maintenance Director, Activities Director, Social Services Director, and other department heads. Each department is assigned specific objectives or focus areas to monitor and report on monthly. During QAPI meetings, department representatives-such as those from nursing, social services, and environmental services. These meetings serve as a collaborative forum for identifying trends, discussing concerns, and exploring opportunities for improvement. 106100 Page 6 of 6