Miami Jewish Health Systems, Inc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews, the facility's staff failed to adequately supervise one (Resident #1) of two vulnerable residents sampled had falls resulting in injuries. On 02/25/2026 vulnerable Resident #1 was left unattended in an unlocked wheelchair by Certified Nursing Assistant Staff A; the wheelchair rolled away and Resident #1 fell from the wheelchair, hit his head on the pavement and sustained major head injuries. There were 235 residents residing in the facility at the time of survey. The findings included: Observation on 3/18/26 at 11:42 AM of the facility's video footage dated 2/25/2026 timestamped 2:30 PM showed Staff A, Certified Nursing Assistant (CNA) escorting Resident #1who was seated in a wheelchair to the door of the auditorium. Staff A, CNA left Resident #1 at the door, did not lock the wheelchair and went inside the auditorium leaving Resident #1 outside. While Staff A, CNA was inside the auditorium, Resident #1's wheelchair started rolling until it came in contact with the sidewalk and Resident#1 fell out of the wheelchair and hit the pavement. A few moments later Staff A, CNA exited the auditorium and checked on Resident #1. Record review of nursing notes dated 2/25/2026 revealed Resident #1 was assessed at approximately 2:30 PM downstairs near the auditorium and found to have sustained a laceration to the left forehead with significant bleeding. An ambulance arrived and transported the resident to a nearby hospital for further evaluation.Record review of nursing notes dated 2/26/2026 indicated the hospital was contacted and revealed Resident#1 had a diagnosis of cerebral brain bleed.Clinical records revealed Resident #1 was admitted to the hospital from [DATE] and returned to the facility on [DATE].Review of Resident #1's hospital records after the incident indicated the resident sustained a contusion and laceration of the cerebrum and brain hemorrhage.Review of Resident #1's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Fall from non-moving wheelchair, Contusion and Laceration of Cerebrum and injury without loss of consciousness, Diffuse Traumatic brain injury with loss of consciousness, Dementia, Functional Quadriplegic and Left-hand Contracture. Record review of Resident #1's fall scale assessments dated 2/15/22, 4/11/22, 4/16/22, 7/17/22, 8/10/22, 3/1/26, 2/04/24, 11/23/25, and 2/23/26 revealed Resident#1 was at a High Risk for falls. Review of Resident #1's fall history revealed the resident sustained falls on 04/11/2022, 04/16/2022, 08/09/2022, 02/04/2024, 02/15/2024 and 02/25/26.Record review of Resident #1's Order Summary Report revealed orders dated 11/20/24 to provide falls precautions as care planned every shift for prevention of falls.Record review of care plans initiated: 02/21/2022 and revised: 02/05/2024 problem focus indicated Resident #1 is at high risk for falls related to history of falls, impaired mobility, difficulty communicating needs, unsteady gait, poor safety awareness, muscle weakness, left side weakness, side effects of psychotropic medications, overestimates ability, adamant to keep his independence with interventions that included: Close supervision, encourage resident to stay in supervised area when in wheelchair and provide safety reminders during rounds and offer assistance with toileting and care. Record review of a Discharge Return Anticipated Minimum Data Set reference dated 2/25/2026 Cognitive Section revealed a Brief Interview of Mental Status (BIMS) score of three out of fifteen indicating severely impaired cognition; Functional Abilities and Goals section indicated Resident #1 required substantial/maximal assistance for toilet transfer/ sit to stand/ chair/bed-to-chair transfer. During a telephone interview on 3/18/26 at 11:26 AM Staff A, CNA stated: [Resident#1] asked to be taken to the auditorium, so I took the resident to the door of the auditorium asked [Resident#1] to wait while I looked inside. When I returned, I saw [Resident#1] was on the ground, laying on stomach. I went inside to get help, and the Patient Assessment Team was called and assessed the resident. I saw there was a cut on the side of the resident's face. Emergency services came and took the resident to the hospital. I don't remember locking the wheelchair. I am aware the wheelchair should be locked. On 3/18/26 at 2:11 PM Resident #1 was observed in the dining room area seated in a wheelchair next to Staff B, CNA. Resident #1 did not respond when greeted and showed little to no facial expressions and a scar was noted on the left side of his forehead.Interview on 3/18/26 at 2:12 PM Staff B, CNA stated, I am the one to one (1:1) monitor assigned to [Resident #1]. I assist the resident with all the ADLs (Activities of Daily Living ) and sometimes the resident talks to me. I notice this resident did not need as much assistance before the fall.Interview on 3/18/25 at 2:15 PM Staff C, Licensed Practical Nurse (LPN) stated, I am the nurse assigned to [Resident #1] today and since the resident returned, I have noticed a slower response time. He now requires maximum assistance.During an interview on 3/18/2026 at 3:25 PM the Risk Manager stated: I was informed about the fall on 2/25/2026 and [Resident #1] was transferred to the hospital and the next day a report was received that a cerebral bleed was sustained, at that time I reported it to state agencies. It was initially reported to me that [Resident #1] attempted to get out the wheelchair however the CNA involved could not remember if the wheelchair was locked. I viewed the video footage that confirmed the wheelchair was not locked and determined to be negligent on our part. During that time Staff A, CNA was placed on administrative leave.Review of the facility's Policy titled Fall Prevention Effective Date: 12/1990 with Revision Dates 03/2020 and 03/2022 indicated:PURPOSE: To ensure the safety and well-being of all Miami Jewish Health residents by identifying risk factors and interventions to reduce the likelihood of Falls.POLICY: It is the policy of Miami Jewish Health to take steps to reduce the number and severity of resident falls through appropriate assessment, evaluation, investigation, root cause analysis, identification of risk factors, and interventions that are appropriate for the resident, in order to prevent occurrence, re-occurrence and reduce the likelihood of significant injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for one (Resident # 55) out of one sampled resident who has a primary diagnosis of Acute Respiratory Failure. As evidenced by the resident's nasal canula (NC) was not in nostrils. The findings included.Observation on 09/16/2025 at 11:07 AM, Resident #55 was in bed with eyes closed, Oxygen (02) running at two (2) Liters per Minute (LPM) via Nasal Canula (NC), NC not in resident's nostrils. The surveyor requested to see the assigned nurse in resident's room.On 09/16/2025 at 11:14 AM Licensed Practical Nurse (Staff F), positioned the 02 tubing in the resident's nostrils, checked the resident's oxygen saturation on the right index finger, the reading was100.On 09/17/2025 at 10:53 AM, Resident #55 was observed in bed, receiving morning care, 02 running at 2 LPM via NC, nasal tubing position correctly in nostrils.During observation on 09/18/2025 at 10:00 AM, Resident #55 noted in room receiving morning care from staff, 02 tubing positioned in nostrils, no distress noted.Review of the medical records for Resident #55 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Atherosclerotic Heart Disease of Native coronary Artery without Angina Pectoris.Review of the Physician's Orders Sheet for September 2025 revealed Resident #55 had orders that included but not limited to: Oxygen 2 LPM via nasal cannula continuous-every shift for shortness of breath.Record review of Resident # 55's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments and Procedures documented the resident is receiving oxygen therapy.Review of Resident #55 Care Plans Reference Date 06/26/25 documented: The resident is on oxygen therapy continuously every shift for shortness of breath, 02 less than 94%. The resident will have no sign and symptoms of poor oxygen absorption through the review date. Interventions include-Change residents position every 2 hours to facilitate lung secretion movement and drainage.Interview on 09/16/2025 at 11:20 AM Licensed Practical Nurse (Staff F) revealed the resident is not alert and oriented and is nonverbal, so education with the resident has not been completed. Staff F stated: I do frequent rounds for this resident because he takes his oxygen tubing off sometimes. Staff F reported she does not know if this a regular behavior for the resident because she does not work with the resident regularly.Interview on 09/16/2025 at 11:38AM, Registered Nurse, Nurse manager (Staff H) stated: This resident pulls his tubing off frequently, the staff have been educated to check on the resident often. The resident is not alert oriented and is non-verbal. As a result, education has not been provided to the resident. All we can do is frequent rounds checking on the resident and alert the nurse if the resident's nasal canula needs to be repositioned correctly.Review of the facility policy and procedures titled, Oxygen Administration revision date November 18, 2024, states: Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. In patients with hypoxemia, the cardiopulmonary system compensated by increasing ventilation and cardiac output. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. Reducing cardiac workload is especially important when disease or injury-such as myocardial infarction (MI), sepsis, or traumas already stressing the heart. Hypoxemia causes pulmonary vasoconstriction and subsequent pulmonary hypertension, which increases the workload of the right side of the heart. Oxygen administration can reverse pulmonary vasoconstriction, decreasing right ventricular workload. Oxygen administration has only limited benefit for treatment of hypoxia caused by anemia because of the blood's limited oxygen-carrying capacity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records reviewed and interviews, the facility failed to ensure narcotics/ controlled substances were reconciled for one ([NAME] 3, Medication Cart #2) out of ten medication carts observed in the facility. There were 288 residents residing in the facility at the time of this survey.The findings include. On 09/17/2025 at 10:00 AM during the narcotic count and review of [NAME] (3) Medication Cart #2 with Licensed Practical Nurse (Staff I), the narcotic count was inaccurate for Resident # 127's Clonazepam oral tablet 1milligrams (mg). The narcotic count sheet revealed that the last tablet was signed out as given at 10:00 PM on 09/16/25 and the remaining tablets noted as 19. The bingo card/packet count was 18. In addition, the narcotic count was inaccurate for Resident # 255's Lacosamide Oral Tablet 100 milligrams (mg) tablet. The narcotic count sheet revealed that the last tablet was signed out as given at 06:39 PM on 09/16/25 and the remaining tablets noted as 56. The bingo card/packet count was 55. Licensed Practical Nurse (Staff I) acknowledged the discrepancies and revealed she forgot to sign out the medication and was trying to sign out the medications before the surveyors got to her cart. Licensed Practical Nurse (Staff I) proceeded to sign out the medication (Lacosamide 100 mg, 1 tablet on the bingo card as given on 9/17/25 at 9:30AM. Review of the Electronic Medication Administration Record (EMAR) revealed Resident # 127's Clonazepam oral tablet 1milligrams (mg), (1) tablet was given on 09/17/25 at 9:00 AM and Resident #255's Lacosamide Oral Tablet 100 milligrams (mg), (1) tablet was given on 09/17/25 at 9:00 AM. Interview on 09/17/25 at 10:05 AM Licensed Practical Nurse (Staff I) revealed the facility's policy is to sign out narcotic medications immediately after taking medications from the bingo card and document as given after the medication has been taken by the resident; and she just did not get around to signing off the medications.Interview on 09/18/25 at 3:30 PM the Director of Nursing (DON) revealed on 09/16/25 they had started Performance Improvement Plans for identified concerns regarding medication administration procedures, protecting Personal Health Information (PHI), signing out control substances. Review of the facility's policy and procedure titled Disposal of Medications and Medication-Related Supplies dated May 2022 states: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal and state laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to follow infection prevention and control procedures for two (Resident #209 and Resident #302) out of 35 residents sampled. As evidenced by Resident #209's Incentive Spirometer and Resident # 302's Bilevel Positive Airway Pressure (BIPAP) machine was observed stored at bedside with no protective covering. The findings include.During observation on 09/16/2025 at 11:47 AM Resident #209 was in bed awake, oxygen (02) running at two (2) Liters per minute (Lpm), Incentive spirometer stored on bedside table with no protective covering (Photographic evidenced).Observation on 09/17/2025 at 11:00 AM and on 09/18/2025 at 01:27 PM the Incentive Spirometer was noted on the bedside table in a resealable plastic bag dated 09/17/25.Review of Resident # 209 medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Chronic Obstructive Pulmonary disease, Chronic Respiratory Failure with Hypoxia.Observation on 09/16/2025 at 11:51 AM Resident # 302 was in bed awake, a BIPAP machine noted on the bedside table with no protective covering (Photographic evidenced).Observation on 09/17/2025 at 10:58 AM and on 09/18/2025 at 2:36 PM the BIPAP machine was observed on the bedside table in a resealable plastic bag dated 09/17/25.Review of the medical records for Resident # 302 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Acute and Chronic Respiratory Failure with HypoxiaInterview on 09/18/25 at 11:18AM Registered Nurse (Staff G) assigned to Resident # 209 and Resident # 302 reported that all respiratory equipment when not being used are stored in a dated [brand] bag, the [brand resealable plastic bags] are changed weekly on Sundays and as needed. We store respiratory equipment in [brand resealable plastic bags] to prevent infection to the residents. During my shift I conduct rounds for my residents every two hours and sometimes more often depending on the resident.Interview on 09/18/25 at 11:26 AM Licensed Practical Nurse (Staff F) assigned to Resident # 209 and Resident # 302's unit revealed, respiratory equipment when not being used is stored in a dated [brand resealable plastic bag], the [brand resealable plastic bags] are changed weekly and as needed. The reason for storing the respiratory equipment in the [brand resealable plastic bag] is to prevent infection. During my shift I check on my residents every one to two hours, high risk residents are checked on every thirty (30) minutes.Interview on 09/18/25 at 11:35AM Registered Nurse Unit Manager (Staff H) was shown photographic evidence. Staff H stated: I will reeducate all the nursing staff on infection control procedures. Respiratory equipment is stored in a dated [brand resealable plastic bag] and changed weekly. The date on the [brand resealable plastic bag] is the date the bag was changed.Review of the facility policy and Procedure titled Infection Prevention and Control Plan dated February 2022 states: The facility maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and healthcare workers. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory and accrediting agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to secure residents' confidential information on two ([NAME]-1st floor, Medication Cart 1 and 5th floor, Medication Cart 2) out of four medication carts: as evidenced by unattended Medication Carts noted with unlocked computer screens displaying residents' confidential information during medication administration. There were 288 residents residing in the facility at the time of the survey.The findings included: Observation on 09/16/2025 at 9:47 AM, on the 5th floor, revealed Medication Cart 2 was left unattended and the computer's screen unlocked with visible resident information. (Photographic evidence). The Surveyor notified Staff C, Registered Nurse (RN) of the identified concern. Staff C, RN revealed she did not realize she had left the computer screen open. On 09/16/2025 at 10:15 AM, observation on the 1st floor revealed Medication Cart 1 unattended and the computer screen unlocked with visible resident information. (Photographic evidence). The Surveyor notified Staff D, RN of the identified concern. Staff D, RN revealed he only stepped a few feet away from the computer to assist a resident and came right back. Record review of a Policy titled, Preparation and General Guidelines: May 2022 indicate:Policy: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is maintained always for all resident information (e.g., Medication Administration Record (MAR) [by closing the MAR book/covering the MAR sheet or computer screen when not in use.Interview on 09/16/2025 at 02:10 PM, the Director of Nursing (DON) stated: During medication pass, the staff member provides privacy depending on the situation and always asks the resident if it is acceptable first. To ensure privacy, the staff either pulls the resident away from others or brings them back to their room. In shared rooms, curtains and doors are closed. Medications may be administered in the activity room, but only with the residents' consent. Before leaving the cart, the staff member locks it and ensures all resident information is secure. The computer screen is never left open unattended and locks automatically every 30 seconds.Interview on 09/16/2025 at 9:47 AM, Staff C, RN stated: I did not realize I left the computer screen open. I receive frequent education from the nurse educator about privacy and HIPAA.Interview on 09/16/2025 at 10:15 AM, Staff D, RN stated: I only stepped a few feet away from the computer to assist a resident and came right back. I have only been a nurse here for one month and recently received education on privacy and HIPPA recently for my training virtually and by my preceptor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for two (Residents #5 and #6) out of three residents sampled, as evidenced by Resident # 5 and Resident # 6 had wander/elopement alarm devices on their left ankle as ordered. However, the Annual MDS indicated the devices were not used. There were 306 residents residing at the facility at the time of the survey.
The findings included:
Resident #5:
On 06/02/2025 at 12:40 PM Resident #5 was observed in the dining room, sitting in her wheelchair eating independently.
Review of Resident #5's medical records revealed the resident was initially admitted to the facility on admitted to the facility on [DATE]. Clinical diagnoses include Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and Alzheimer's disease.
Review of Resident # 5's Physician's Orders Sheet and Electronic Treatment Administration Records for June 2025 revealed an order with start date 11/09/2023 for Electronic wandering device to the left ankle. Check if the device is in place and functioning every day shift every Thursday for Elopement risk and every shift.
Review of Resident #5's Care Plans initiated 10/26/2023, revision dated 05/28/2025, target date 07/21/2025, revealed Resident #5 is at risk for elopement or wandering related to impaired safety awareness, Resident wanders aimlessly. Interventions include- Assess resident for risk of elopement or wandering. Resident has wandering device in place to left ankle and will be checked every Thursday.
Review of Resident #5 's Annual MDS assessment dated [DATE] indicated in Section C for Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 to suggest severe cognitive impairment. Section P- Restraints and Alarms-P0200-Alarms: An alarm is any physical or electronic device that monitors resident movement and alerts; Item E-Wander/elopement alarm coded 0=Not used.
Resident #6:
On 06/02/2025 at 12:45 PM, Resident #6 was observed in common area sitting in her wheelchair eating lunch supervised by staff.
Review of the medical records for Resident #6 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and Schizoaffective disorder bipolar type.
Review of Resident #6's Physician's Orders Sheet for June 2025 revealed order dated 04/13/2023 and 04/04/2025 for: Electronic wandering device to the left ankle. Check if the device is in place and functioning every day shift every Thursday for Elopement risk and every shift.
Record review of Resident #6's Care Plans initiated 12/11/2021, Revised 04/22/2025; Target date 09/02/2025 revealed Resident #6 is at risk for exit seeking behaviors related to cognition and disorientation to place, she has impaired safety awareness due to dementia. Interventions include- Check wandering left ankle for functioning and placement. Distract resident from wandering by offering pleasant diversions, structured activities .
Record review of Resident #6 's Annual MDS assessment dated [DATE] revealed in Section C for Cognitive Pattern indicates a Brief Interview for Mental Status (BIMS) score of 03 out of 15 to suggest severe cognitive impairment. Section E for Behavior documented verbal behavioral symptoms occur 1 to 3 days and rejection of care occurs 4 to 6 days. Section P- Restraints and Alarms/P0200-Alarms: An alarm is any physical or electronic device that monitors resident movement and alerts; Item E-Wander/elopement alarm coded 0=Not used.
Interview on 06/02/25 at 02:00 PM with Staff A, MDS Coordinator stated: The [Wander Alert Device] are coded under section P in the MDS. I code them once the MDS is completed and if the resident is wearing the device at the time of the assessment. [Residents #5 and #6] were miscoded and it was an oversight .
Review of the facility's policy and procedure dated March 2022 indicate it is the policy of Miami Jewish Health to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of all residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews facility failed to administer medications as ordered by a physician in accordance with professional standards for two residents (Resident #1 and Resident #6) out of four sampled residents as evidenced by staff failed to administer an accurate dose of a laxative for Resident #1 and failed to administer a blood pressure lowering medication as ordered for Resident #1.
The findings included:
Observation on 2/25/25 at 9:12 AM of Resident # 6's medication administration being completed by Staff B, Registered Nurse (RN) revealed the medications administered by mouth included Lactulose 15 ml (milliliters). The label on the bottle of Lactulose read 30 ml daily by mouth (photographic evidence).
Review of Resident #6's physician orders revealed order dated 2/21/25: Lactulose Oral Solution 10 gm/15 ml (grams/milliliters) directions: Give 15 ml by mouth in the morning for constipation.
Record review of Resident #6's demographic sheet revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that include constipation.
Review of Resident #6's Brief Interview for Mental Status (BIMS) revealed a score of 10 out of 15 to indicate moderate cognitive impairment.
During an interview on 2/25/25 at 1:45 PM, Staff B, RN was asked about the discrepancies in the label on the Lactulose bottle and the current order noted on the Electronic Medication Administration Record (MAR). At that time Staff B, RN referred to the physical chart and presented a physician orders worksheet dated 2/21/25; the document presented revealed physician ordered to lower Lactulose to 10cc daily.
Interview on 2/25/25 at 2:45 PM with the Director of Nursing (DON) about The Lactulose order for Resident # 6; the DON stated: The Lactulose order was clarified with the physician and the order should have been 10 ml daily. An incident report was completed. [Resident #6] was not harmed.
Review of a demographic sheet for Resident#1 revealed an admission date of 1/29/25, readmission date of 2/6/25, discharge date s of 2/4/25 and 2/14/25 with diagnosis that included: Hypertensive Heart Disease and Chronic Kidney Disease.
Record review of a Medicare 5 day/ Modification of Discharge Return Anticipated MDS (Minimum Data Set) reference dated 2/4/25 revealed Resident #1's Brief Interview for Mental Status (BIMS) score was undetermined, and the resident required substantial/maximal assistance for eating and was dependent on staff for transferring.
Record review of Resident #1's physician's orders sheet revealed orders dated 1/30/25 for Midodrine Hydrochloric Acid Oral Tablet 5 mg (Midodrine HCl) directions: Give one tablet via Percutaneous Endoscopic Gastrostomy (PEG) Tube every eight (8) hours for Hypotension (Low Blood Pressure) and Vital Signs every 8 hours, 2/7/25 Midodrine HCl Oral Tablet 5 mg (Midodrine HCl) directions: Give 1 tablet via PEG-Tube every 8 hours for hypotension (stopped on 2/10/25) and 2/10/25 Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) directions: Give 1 tablet via PEG-Tube every 8 hours as needed for hypotension for systolic (the top number of a blood pressure reading) less than 100.
Review of Nursing Notes revealed on 2/9/25 at 2:24 PM [Resident #1] was noted with High Blood Pressure (B/P) during my shift, resident does not have any hypertension medication, patient had Midodrine scheduled which was not administered. I explained to the son who was in the room that I will contact the Doctor to get an order for hypertension medication, Son verbalizes been scared to Mom's B/P went low with BP medication. I contacted Dr and explained concerns and allergies and also suggested as needed (PRN) medication. Doctor ordered Lisinopril 2.5 mg daily. Son explained about order, medication, dose and time and he verbalized to be agreed.
Record review of The Electronic Medication Administration Record and Treatment Administration Records for January and February 2025 revealed Midodrine 5 mg was administered on 1/31/25 at 6:00 AM the recorded B/P was 138/ 71, on 1/31/25 at 2:00 PM the recorded B/P was 167/72, on 1/31/25 at 10:00 PM the recorded B/P was 131/ 60, on 2/1/25 at 2:00 PM the recorded B/P was 143/ 63, on 2/2/25 at 2:00 PM the recorded B/P was 138/65, on 2/7/25 at 2:00 PM the recorded B/P was 136/79, on 2/7/25 at 10:00 PM the recorded B/P was 158/84 and on 2/8/25 at 2:00 PM the recorded B/P was 136/72.
Interview on 2/25/25 at 2:20 PM, the Director of Nursing (DON) was asked when nursing staff are required to hold Midodrine if there are no parameters in the order. The DON stated: We practice not to have parameter as standard orders for medications affecting the blood pressure. If a parameter is set that is per physician's order. Our standard is to check residents blood pressure every 8 hours. We also have a reference booklet available to nursing staff if they have any questions about medications. It is located on their laptop. When there is no parameter, the physician did not order it. We have a system where medications are triple checked during the reconciliation process when residents are admitted .
On 2/25/25 at 3:45 PM the Staff Pharmacist was asked about the proper administration including parameters of Midodrine; the Pharmacist stated: There is no guidance that says when Midodrine can or cannot be administered. The only contraindication is persistent and excessive supine hypertension. Routine orders for Midodrine don't usually have parameters.
Record review of a policy provided titled, Preparation and General Guidelines, May 2022 revealed IIA2: Medication Administration -General Guidelines. Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.

Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals stored and labeled in accordance with professional principles, as evidenced by one out of three medication carts sampled was left unlocked and unattended with a medical ointment on top of the cart; and discrepancy with labeled orders and Electronic Medication Administration (EMAR).
The findings included:
On 2/25/25 at 8:43 AM during observation of medication administration conducted by Staff A, Licensed Practical Nurse (LPN) on the 2nd floor, Staff A, LPN stepped away from the medication cart to use the telephone at the nursing station, leaving the medication cart unlocked and a medical ointment on top of the cart. When Staff A, LPN returned to the cart the surveyor asked Staff A,LPN about the protocol for securing medication and storing ointments; Staff A,LPN replied: The cart should be locked when I walk away. The reason I left the cart unlocked when I walked away was because I could still see the cart. It is not okay to leave the cart unlocked. Ointments are kept in the treatment cart. I found this ointment and forgot to place it in the treatment cart.
2)On 2/25/25 at 9:12 AM a medication administration observation was conducted on the 2nd floor with Staff B, Registered Nurse (RN). Staff B, RN administered 15 ml (milliliters) of Lactulose solution as documented in the Electronic Medication Administration Record. However, the Lactulose bottle was labeled to administer 30 ml daily.
Record review of a Policy titled, Medication Storage in the Facility dated April 2018 ID1: Storage of Medications revealed Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to complete a self-administration of medication assessment for two residents (Resident #294 and Resident #648) out of ten residents sampled as evidenced by an observation of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at Resident # 294's and a box labeled Diclofenac Sodium Topical Gel 1 % ointment and a bottle labeled Valerian Extract supplement at Resident #648's. Both residents did not have a self-administration of medication assessment on file. There were 296 residents residing in the facility at the time of survey.
On 05/06/2024 at 12:05 PM an observation was made of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at bedside of Resident #294.
On 05/06/2024 at 12:05 PM Staff A, Registered Nurse (RN) stated: I am the nurse assigned to [Resident #294]. I am not aware of [Resident #294] being able to self-medicate or keep medications at the bedside and I will follow up with the supervisor. Staff A, RN removed medication from bedside.
Record review of demographic sheet for Resident #294 revealed an admission date of 4/19/2024 with diagnosis that included Thrombocytopenic Purpura.
Record review of admission Minimum Data Set (MDS) dated [DATE], Section C for cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Section GG for functional status revealed the resident set up/clean up assistance for eating/oral hygiene, substantial maximal assistance for toileting/ upper body dressing, and dependent for shower/bathe/transfer.
Record review of activities of daily living deficit related weakness care plan initiated 4/20/2024 for Resident #294 revealed interventions included totally dependent for bathing, dressing and toileting with the assistance of one to two people.
Record review of physician orders for Resident #294 on 05/06/2024 revealed no order found for Immune Support Bio-active silver hydrosol.
Record review of assessments revealed no self-administration of medication on file.
On 05/09/2024 at 12:22 PM Staff C, RN, stated: I am the charge nurse for this unit. For a resident to be allowed to self-medicate, a self-administration of medication assessment must be completed and an order from the doctor obtained. A self-administration of medication assessment was completed for [Resident #294] after the surveyor brought it to our attention that the medication was in the room.
Observation on 05/06/2024 at 9:47 AM in Resident #648's room revealed a box labeled Diclofenac Sodium Topical Gel 1 % ointment and a bottle labeled Valerian Extract supplement at the resident's bedside. (photo evidence)
On 05/06/2024 at 9:47 AM, Resident #648 stated: I use the ointment when the nurse isn't available and the drops to assist with falling asleep.
On 05/06/2024 at 12:21 PM Staff B, RN stated: I am not aware of [Resident # 648] being allowed to self-medicate. Staff B, RN entered the room with the surveyor and Staff B, RN removed medications from the bedside and stated I will follow up with charge nurse and physician.
Record review of demographic face sheet for Resident # 648 revealed an admission date of 4/28/2024 with diagnosis that included Aftercare following joint replacement surgery, need for assistance with personal care.
Record review of the 5-day MDS dated [DATE] Section C revealed a BIMS score of 11, indicating moderate cognitive impairment. Section GG revealed Resident #648 was independent with eating, supervision or touching assistance for oral hygiene and partial moderate assistance for toileting.
Record review of physician orders revealed an order dated 4/28/2024 for Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical) Apply to Whole Body topically four times a day for Joint Pain. No physician orders noted at that time for Valerian Extract.
Review of the care plans documented self-care deficit and is at risk for further decline related to (r/t) Activity intolerance, Impaired mobility, Recent surgery to right knee, generalized weakness Care Plan initiated on 04/30/2024 revised on 04/30/2024. Interventions included ok for patient to self-administer Valerian Extract supplement, initiated on 05/06/2024.
Record review of assessments revealed no self-administration of medication assessment on file.
On 05/09/2024 at 11:22 AM Staff D, Licensed Practical Nurse (LPN) stated: I am the charge nurse of this unit. Residents can self-administer medications once a physician's order is obtained. No medications should be kept in the room without a physician's order. [Resident #648], brought this medication from the hospital and staff were not aware of medications being in the room. I spoke to the doctor and an order was obtained for [Resident # 648] to keep the herbal extract in room and the ointment was removed.
On 05/09/2024 at 10:23 PM The Director of Nursing (DON) stated that any resident who wishes to self-administer medication, a self-administration assessment must be on file.
Record review of Policy and Procedure entitled: Preparation and General Guidelines April 2018. IIA10: Self-Administration of Medications. Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide assistance during dining observation for 1 (Resident #293) of 6 residents reviewed for nutrition.
The findings included:
In an observation conducted on 12/12/22 at 1:00 PM, Resident #293 was noted in her room with the lunch tray. The lunch tray was observed to be 100% untouched, and no staff was noted in the room. Continued observation at 1:25 PM showed no staff in the room assisting Resident #293 with her lunch meal.
In an observation conducted on 12/13/22 at 8:03 AM, Resident #293 was noted in her room with the breakfast tray in front of her. The tray was set up, and some of the food was cut into smaller pieces, but no staff was noted in the room. It was noted that 50 % of the [brand] nutritional supplement was 50% consumed. The food on the tray was noted to be 100% untouched. At 8:17 AM, showed Staff in the room standing over Resident #293, asking her if she wanted to eat. At 8:18 AM, Staff noted walking out of the room, and the food on the tray was still 100% untouched. Continued observation showed that at 8:28 AM, the tray was still 100% untouched with no staff assistance in the room. (Photographic evidence obtained)
A chart review showed that Resident #293 was admitted on [DATE] with diagnoses of dysphagia, muscle weakness, and acute kidney failure. The Minimum Data Set (MDS) dated [DATE] showed that Resident #293 had a Brief Interview of Mental Status (BIMS) score of 03, which is severely cognitively impaired. It further showed that under eating in Section G, Resident #293 needs extensive assistance with one person assists during dining.
A Physician order noted for a Mechanical Soft/Ground texture, Thin Fluids consistency, for Diet/Nutrition dated 12/01/22, and at risk for Malnutrition dated 11/14/22.
A Mini Nutritional assessment dated [DATE] showed that Resident #293 is malnourished. The Nutrition Risk assessment dated [DATE] showed that Resident #293 had a weight loss before her admission to the facility. It further showed that Resident #293 had a 50% intake of meals with supervision to total assistance. Resident #293's fluid intake did not meet her estimated needs, and her food intake met 60% of her estimated needs.
A review of the Dietary note dated 12/09/22 showed Nursing reports poor appetite x (times)1 week and that Resident #293 is with 100% intake of supplements and 0% intake at meals.
The Care plan dated 11/29/22 showed that Resident #293 has the potential/actual nutritional problems related to Chewing/swallowing difficulty and is dependent on eating and drinking.
In an interview conducted on 12/14/22 at 5:20 PM with Staff D, Certified Nursing Assistant, was asked if Resident #293 needs help with her meals, Staff D stated, yes, she is a Feeder. When asked by surveyor what that meant, Staff D reported that the resident needed total assistance in the room with all her meals.
In an interview conducted on 12/14/22 at 5:30 PM, Resident #293's daughter stated that Staff told her that her mom was not eating at all. She further said that when she comes to see her mom, the Staff say that they will come back to help her with her meals, but they never return to the room.
In an interview with the facility ' s Administrator on 12/15/22 at 11:20 AM, he was told of the findings.
Class III

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the correct food consistencies for the ordered Pureed diets during dining observations and the second tour of the main kitchen. This has the potential to affect 52 residents residing in the facility on a Pureed diet.
The findings included:
A review of the Nation Dysphagia Diet Pureed Nutrition Therapy dated September 24, 2019, which Staff E, Registered Dietitian provided, showed the following: Pureed diet is indicated for the resident who has difficulty chewing or swallowing food items and benefits from stricter modifications of food textures to provide foods that can be successfully and safely swallowed. This diet consists of foods that are easy to swallow because they are pureed, smooth, and lump-free, not firm or sticky_ Foods do not require any chewing and may be prescribed due to several medical conditions.
In an observation conducted on 12/12/22 at 1:00 PM, Resident #751 was noted in her room with her lunch tray. Closer observation showed the following: a lunch plate of pureed white rice, pureed red cabbage, and 2-inch pieces of beef stew cubes that did not have the same consistency as the pureed rice or the pureed red cabbage. Continued observation showed Resident #751 struggled to cut through the cubed beef stew. (Photographic evidence obtained).
A chart review showed that Resident #751 was admitted on [DATE] with a diet order of No Added Salt Pureed texture diet, which was dated 12/12/22.
In an observation conducted on 12/14/22 at 11:25 AM, during the lunch meal tray line, two plates of Pureed diet were observed with the following: pureed yellow squash, pureed white rice, and a sizeable, molded piece of seared tilapia (fish) that did not have the same consistency as the white rice or the yellow squash. (Photographic evidence obtained).
In this observation, Staff A, Execute Chef, and Staff E, a Registered Dietitian, in the presence of two state surveyors, were asked to take a spoon and cut through the consistency of yellow squash, white rice, and tilapia. Continued observation showed that Staff A could smoothly cut through the white rice and the yellow squash. When attempting to cut through the tilapia, he used more force to cut through, and the consistency of the tilapia was observed with small lumpy pieces. Staff E was then asked to try and cut through the tilapia, yellow squash, and white rice. She acknowledged that more force was used to cut through the fish than the yellow squash or the white rice. Staff E also stated that while cutting the foods, the feeling of consistency was different between the yellow squash and the white rice in comparison to the tilapia. (Photographic evidence obtained).
In an interview conducted on 12/14/22 at 11:40 AM with Staff A, the Executive Chef stated that he pureed the tilapia using a blender and used a thickener to mold the fish into the shape that was observed. He then used round tubes to shape them into a firmer shape, so they have a nice appearance on the plate.
In an interview conducted on 12/14/22 at 12:07 PM with Staff B and Staff C, Speech Language Pathologists, they stated that pureed diet is completely blended with no chewing involved. When asked if there are several pureed diet levels, they said no. They further stated that they had yet to observe the cooking process in the kitchen for the pureed diet consistencies. According to Staff B and Staff C, the pureed diet should not have lumps or pieces.
In an interview conducted on 12/14/22 at 12:20 PM Staff E, Registered Dietitian, acknowledged all findings. She further stated that 52 residents in the facility are on a pureed diet.