Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Miami Shores Nursing And Rehab Center during CMS and state inspections, most recent first.
A CNA failed to perform hand hygiene, change gloves, or use separate washcloths during hygiene care for a resident on enhanced barrier precautions with a PEG tube. The resident, who was cognitively impaired and fully dependent for ADLs, was left uncovered during care, and the same washcloth was used for the face and body, contrary to facility policy and infection control standards.
Staff failed to consistently document the removal and administration of controlled substances at the time of dispensing, resulting in unreconciled narcotic logs and discrepancies with the EMAR. In several cases, nurses either delayed signing the logs, omitted required information, or reinforced damaged bingo cards with tape instead of returning them to the pharmacy, contrary to facility policy.
The QAPI committee failed to implement effective corrective actions for previously identified deficiencies, resulting in repeated issues with infection prevention—such as improper PPE use, poor hand hygiene, and environmental cleanliness—and medication management, including unattended medication carts and unsecured medical supplies at a resident's bedside.
The facility failed to maintain its automatic sprinkler system according to NFPA 101 standards. During a survey, it was found that the Rehabilitation Standpipe Room lacked a posted list in the sprinkler cabinet and a spare dry sprinkler for the freezer. The Maintenance Director acknowledged these deficiencies, which were also discussed with the Administrator.
The facility failed to maintain compliance with NFPA 101 standards by not providing the required clean agent fire extinguishers in the Telecommunication Equipment Room (TER) within the Rehabilitation Room. This deficiency was observed during a life safety tour with the Maintenance Director, who acknowledged the issue, and was further discussed with the Administrator during the exit conference.
During a Life Safety Survey, a facility was found non-compliant with NFPA 101 smoking regulations. The designated smoking area lacked noncombustible ashtrays and metal containers with self-closing covers for ashtray disposal. The Maintenance Director and Administrator acknowledged these deficiencies during the survey and exit conference.
The facility failed to maintain its essential electric system generator according to NFPA 101 standards. There was no documentation for the fuel quality test since May 2023, and no generator high mortality spare parts were available on the premises. These deficiencies were acknowledged by the Maintenance Director and discussed with the Administrator.
During a Life Safety Survey, it was found that the Oxygen Storage Room lacked the required precautionary signage stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." This deficiency was acknowledged by the Maintenance Director and discussed with the Administrator, indicating non-compliance with NFPA 99 and NFPA 101 standards.
The facility failed to follow infection control protocols, with staff entering precaution rooms without PPE and improper hygiene practices. A resident with an open wound was non-compliant with treatment, and environmental issues like trash in the pantry and unsecured utility room doors were noted. These deficiencies highlight lapses in maintaining a safe and sanitary environment.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident had no care plan intervention for floor mats, another had an initially incomplete care plan for floor mat use, and a third lacked a care plan for a required C-collar. These omissions resulted in inadequate documentation and implementation of necessary interventions.
The facility failed to properly store medications, as expired Covid-19 test kits were found in a medication storage room, an unlocked medication cart was observed, and a nurse left a cup of crushed medication and a lancet unattended in a resident's room. The RN supervisor confirmed the expired kits, and the DON stated the tests could still be used due to an extended expiration date. The RN admitted to leaving the cart unlocked and the medication unattended due to being in a hurry and the presence of a surveyor.
A resident's medical records inaccurately documented a COVID-19 positive status and treatment with a Z pack, despite being COVID-19 negative and not receiving such medication. This discrepancy was confirmed by the DON and an LPN, highlighting a failure to maintain accurate records as per facility policies.
A tripping hazard was identified in a resident's room due to an electrical cord for an air mattress being improperly secured, creating a risk of falls. The resident, who had a history of acute failure and COVID-19, was dependent on staff for transfers. Despite facility policies emphasizing safety, the hazard was not addressed until pointed out by a surveyor.
A resident in a facility was observed with kinked and improperly draining tubing, which was also found touching the floor. Despite staff rounds and communication, the tubing issues persisted, indicating a lapse in monitoring. The resident had a significant change in status, and there was confusion among staff regarding the type of system in use, leading to inadequate care.
The facility failed to protect residents' privacy by leaving computer screens unlocked and unattended, displaying resident information. An RN and an LPN were involved in separate incidents where computer screens were left open, violating the facility's privacy policy. The policy requires all patient information to be confidential and stored securely, with access restricted to authorized personnel.
The facility failed to maintain the privacy and confidentiality of residents' information, as two computer screens on the East side nursing station were left unlocked and unattended, displaying resident data. An RN and an LPN were involved in the incidents, acknowledging the breach of protocol. The facility's policy mandates confidentiality and restricted access to patient information, which was not adhered to, resulting in a deficiency.
The facility failed to accurately complete PASARR Level I screenings for three residents, leading to discrepancies in their care needs. The screenings did not reflect the residents' current diagnoses and medication requirements, as confirmed by the DON and other staff. This deficiency was identified during a survey through observations, record reviews, and staff interviews.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident lacked a care plan for floor mats, another had an outdated care plan for floor mat interventions, and a third resident did not have a care plan for a required C-collar. These oversights resulted in inadequate documentation and planning for the residents' safety and care needs.
A resident's room in an LTC facility was found to have a tripping hazard due to an improperly managed electrical cord for an air mattress. The cord was wrapped around a side table and suspended in the air, posing a risk. The resident, who had a history of acute failure and COVID-19, was dependent on staff for transfers. The facility's policy aimed to minimize accident hazards, but this incident highlighted a failure to adhere to safety protocols.
A facility failed to provide appropriate catheter care for a resident, as the tubing was observed kinked and touching the floor, hindering proper drainage. Despite staff rounds and communication, the tubing was found improperly positioned, indicating a lapse in care. The DON acknowledged the issue, noting outdated physician orders and emphasizing the need for proper monitoring to prevent infections.
The facility failed to properly store medications, with expired Covid-19 test kits found in a storage room, an unlocked medication cart left unattended, and a nurse leaving medication and a lancet unattended in a resident's room. These incidents highlight lapses in adhering to protocols for safe and secure medication storage and handling.
The facility failed to properly dispose of cardboard boxes, which were found scattered on the ground outside the kitchen door instead of being placed in the garbage bin as per policy. A Dietary Aide and the Dietary Director confirmed that the boxes should have been disposed of properly.
A resident's medical record inaccurately documented a COVID-19 positive status and treatment with a Z pack, despite the resident being COVID-19 negative and not receiving such medication. This discrepancy was confirmed by the DON and an LPN, highlighting a failure to adhere to the facility's policy on accurate documentation.
The facility failed to implement effective infection control protocols, as evidenced by non-compliance in a soiled utility room and inadequate hygiene for a resident. Despite monthly QAPI meetings, the facility has a history of repeated deficiencies in infection prevention, affecting its ability to provide safe care.
The facility failed to maintain accurate MDS records for two residents, leading to deficiencies in their care plans. One resident was incorrectly coded as a hospice resident without hospice orders, and another was inaccurately coded as returning to a hospital instead of being discharged to an ALF. These errors highlight lapses in documentation and communication within the facility.
The facility failed to maintain accurate MDS assessments for two residents, leading to discrepancies in their care needs and discharge plans. One resident was incorrectly coded as a hospice resident, while another was inaccurately documented as returning to a hospital instead of being discharged to an ALF. These errors were due to oversight by the MDS Coordinator, despite existing communication processes with nursing and social services.
A facility failed to implement a Restorative Care Plan for a resident with a physician's order to wear a C-collar at all times. Observations showed the resident often without the C-collar, and staff interviews revealed inconsistencies in following the order. The C-collar was found in the laundry, wet, and not available for use, and there was no documentation of deviations from the physician's order in the resident's medical records.
Failure to Follow Infection Control Protocols During Resident Hygiene Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to adhere to infection control standards during hygiene care for a resident on enhanced barrier precautions. The CNA did not perform hand hygiene before the procedure, nor did she change gloves or washcloths at appropriate intervals. The CNA was observed wearing a gown, mask, and gloves upon entry, but did not remove gloves or perform hand hygiene at any point during the care. The same washcloth was used to cleanse the resident's face and the rest of the body, and the resident was left uncovered while the basin was filled with water and soap was added directly to the water. The resident involved had a percutaneous endoscopic gastrostomy (PEG) tube and was under enhanced barrier precautions as ordered by a physician. The resident was cognitively impaired, fully dependent for activities of daily living, and had multiple diagnoses including dysphagia, diabetes mellitus, osteoarthritis, hyperlipidemia, dementia, and GERD. The care plan specified the need for enhanced barrier precautions during hygiene care, including education for caregivers and adherence to infection control guidelines. Facility policy required staff to maintain resident dignity by keeping them covered during care, to use a clean part of the washcloth for each body area, and to perform hand hygiene in conjunction with glove use. Staff interviews confirmed knowledge of these protocols, including the need to change gloves and use separate washcloths for different body areas. However, the observed care did not follow these established procedures, resulting in a failure to meet infection control standards.
Failure to Properly Store and Document Controlled Substances
Penalty
Summary
The facility failed to properly store and document controlled substances on three out of four medication carts, as evidenced by unreconciled medication monitoring/control record sheets. During medication administration observations, staff were found to be signing the narcotic log after administering the medication rather than at the time of removal from the bingo card, resulting in inaccurate and untimely documentation. In one instance, a nurse admitted to forgetting to sign the log at the time of administration, and in another, a nurse did not sign the sheet due to not having a pen. Additionally, discrepancies were noted between the narcotic logs and the electronic medication administration records (EMAR), with missing dates, times, and signatures. Further observations revealed a bingo card containing controlled substances with a broken seal that had been reinforced with tape, contrary to facility protocol, which requires damaged cards to be returned to the pharmacy. The Director of Nursing confirmed that the expected procedure is for nurses to document the date, time, amount, and their initials at the time the medication is removed from the bingo card, and that any abnormalities in the bingo card should be reported to the pharmacy. The facility's policy also requires accurate and timely documentation of controlled substance administration, which was not consistently followed.
Repeated Deficiencies in Infection Control and Medication Management
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA)/QAPI committee failed to demonstrate an effective plan of action to correct previously identified quality deficiencies, as evidenced by repeated citations for F880-Infection Prevention and Control and F761-Label/Store Drugs and Biologicals. During a recertification survey, surveyors observed ongoing issues such as trash and food left on the floor in a resident pantry, an indwelling catheter tube touching the floor, staff not wearing proper personal protective equipment (PPE), and improper hand hygiene during wound care. Additionally, an unattended and unlocked medication cart was found, and medication, a glucometer, and lancets were left at a resident's bedside. The facility's QAPI plan outlines a multidisciplinary committee and a systematic approach to monitoring and improving care, but the repeated deficiencies indicate that these processes were not effectively implemented or sustained. At the time of the survey, there were 91 residents in the facility. The QAPI committee, which includes the DON, department heads, administrator, wound care nurse, dietary staff, and medical director, meets monthly to review quality initiatives and audit outcomes, but the cited deficiencies persisted in the areas of infection control and medication management.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 standards. During a Life Safety Survey tour, it was observed that the Rehabilitation Standpipe Room lacked a posted list in the sprinkler cabinet. Additionally, there was no spare dry sprinkler available for the freezer, nor was there a means to restore service in case of a malfunction. These deficiencies were identified during an inspection conducted at 2:43 pm on April 1, 2025, with the Maintenance Director present. The absence of essential components and documentation in the sprinkler system indicates a lapse in the facility's adherence to the required safety protocols. The Maintenance Director acknowledged these findings during the staff interview, and the issues were also discussed with the Administrator during the exit conference. The report cites specific sections of NFPA 101 and NFPA 25 that were not met, highlighting the facility's failure to comply with established fire safety standards.
Plan Of Correction
This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. **K353 Sprinkler System Maintenance and Testing** **Identify patients that were at risk and what did:** When the surveyor identified the issue we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **How will you identify other patients that are at risk?** When the surveyor identified the issue, we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in the room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **Measure put in place:** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. **How will you monitor?** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. Any Variances will be brought to the QAPI Committee. 5/1/25 This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. **K353 Sprinkler System Maintenance and Testing** **Identify patients that were at risk and what did:** When the surveyor identified the issue we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **How will you identify other patients that are at risk?** When the surveyor identified the issue, we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in the room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **Measure put in place:** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. **How will you monitor?** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. Any Variances will be brought to the QAPI Committee.
Failure to Maintain Required Fire Extinguishers in TER
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards regarding the maintenance of portable fire extinguishers. During a life safety tour conducted at 2:40 p.m. on April 1, 2025, it was observed that the Telecommunication Equipment Room (TER) in the Rehabilitation Room lacked the required clean agent fire extinguishers. This deficiency was identified during an inspection with the Maintenance Director present. The Maintenance Director acknowledged the absence of the necessary fire extinguishers during a staff interview conducted at the same time. This issue was further discussed and acknowledged by the facility's Administrator during the exit conference. The deficiency was noted under NFPA 101 (2021 Edition) and NFPA 10 (2018 Edition) standards, indicating a failure to adhere to the required fire safety protocols.
Plan Of Correction
Sprinkler System Maintenance and Testing Identify patients that were at risk and what did: When the surveyor identified the issue we contacted vendor and ordered a new Clean Agent Fire Extinguisher to be added to the Telecommunication room. This was installed on 4/17/2025. How will you identify other patients that are at risk? No other residents were identified at risk. When the surveyor identified the issue, we contacted vendor and ordered a new Clean Agent Fire Extinguisher to be added to the Telecommunication room. This was installed on 4/17/2025. Measure put in place: The Director of Plant Operations has added the new extinguishers to his monthly checks for compliance. The Director also checked the rest of the extinguishers to ensure they were ready for use. How will you monitor? The Director of Plant Operations has added the new extinguishers to his monthly checks for compliance. Any variances will be brought to the QAPI Committee.
Smoking Area Safety Deficiency
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations during a Life Safety Survey. The survey, conducted with the Maintenance Director, revealed deficiencies in the designated smoking area. Specifically, the area lacked ashtrays made of noncombustible material and safe design, as well as metal containers with self-closing cover devices for emptying ashtrays. These observations were made at 2:10 pm on April 1, 2025. During the staff interview conducted at the same time, the Maintenance Director acknowledged the absence of the required safety equipment in the smoking area. This acknowledgment indicates that the facility was aware of the deficiency at the time of the survey. The findings were also discussed and acknowledged by the Administrator during the exit conference, further confirming the facility's awareness of the issue. The report does not mention any specific patients involved or affected by this deficiency. The focus is solely on the facility's failure to maintain the smoking area in accordance with the NFPA 101 standards, which are designed to ensure safety in areas where smoking is permitted. The lack of proper equipment in the smoking area represents a failure to adhere to established safety protocols.
Plan Of Correction
Smoking Regulations Identify patients that were at risk and what did: When the surveyor identified the issue, we researched and purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you identify other patients that are at risk? No other patients are a risk as the Ashtrays have been replaced with self-closing metal lids and added the RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. Measure put in place: Purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you monitor? The Director of Plant Operations and Housekeeping will be responsible for ensuring that the ash trays are emptied on a regular basis. This is part of our daily service. Any Variances will be brought to the QAPL Committee. 5/1/25 K741 Smoking Regulations Identify patients that were at risk and what did: When the surveyor identified the issue, we researched and purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you identify other patients that are at risk? No other patients are a risk as the Ashtrays have been replaced with self-closing metal lids and added the RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. Measure put in place: Purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you monitor? The Director of Plant Operations and Housekeeping will be responsible for ensuring that the ash trays are emptied on a regular basis. This is part of our daily service. 5/1/25
Deficiency in Essential Electric System Maintenance
Penalty
Summary
The facility failed to maintain its essential electric system generator in accordance with NFPA 101 standards. During a records review process conducted with the Maintenance Director, it was discovered that there was no documentation available for the performance of the fuel quality test since a report dated May 24, 2023. This lack of documentation was acknowledged by the Maintenance Director and discussed with the Administrator during the exit conference. Additionally, during a Life Safety Survey tour of the facility, it was observed that there were no generator high mortality spare parts available on the premises. This observation was made in the presence of the Maintenance Director, who acknowledged the finding. The absence of these critical spare parts was also discussed with the Administrator during the exit conference. The report highlights that the facility did not meet the requirements for maintaining the essential electric system generator as per NFPA 101. The findings were based on both the lack of documentation for fuel quality testing and the absence of necessary spare parts for the generator, which are crucial for ensuring the generator's operational readiness and compliance with safety standards.
Plan Of Correction
Identify patients that were at risk and what did: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you identify other patients that are at risk? No other patients are a risk as the testing was completed on 4/07/2025 and results were pending. On 4/11/25 the Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. Measure put in place: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you monitor? The Director of Plant Operations will be responsible to ensure that the Fuel test is pre-scheduled for annual requirement and that the high mortality parts are always available. Any variances will be brought to the QAPI Committee. K918 Essential Electrical Systems Identify patients that were at risk and what did: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you identify other patients that are at risk? No other patients are a risk as the testing was completed on 4/07/2025 and results were pending. On 4/11/25 the Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. Measure put in place: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you monitor? The Director of Plant Operations will be responsible to ensure that the Fuel test is pre-scheduled for annual requirement and that the high mortality parts are always available. Any variances will be brought to the QAPI Committee. 5/1/25
Missing Precautionary Signage in Oxygen Storage Room
Penalty
Summary
The facility was found to be non-compliant with NFPA 99 and NFPA 101 standards regarding the storage of gas equipment, specifically oxygen cylinders. During a Life Safety Survey tour, it was observed that the Oxygen Storage Room by the Southwest Exit lacked the required precautionary signage. The sign was missing the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," which is a mandatory requirement for safety and compliance. The deficiency was identified during an inspection conducted at 2:30 pm on April 1, 2025, with the Maintenance Director present. The absence of the necessary signage was acknowledged by the Maintenance Director during the survey. This oversight indicates a failure to adhere to the safety protocols outlined in NFPA 99 and NFPA 101, which are designed to ensure the safe storage and handling of gas cylinders to prevent potential hazards. The issue was further discussed and acknowledged by the facility's Administrator during the exit conference. The lack of proper signage in the oxygen storage area represents a significant oversight in maintaining the required safety standards for gas equipment storage, as stipulated by the relevant NFPA codes.
Plan Of Correction
K923 Cylinder and Container Storage Identify patients that were at risk and what did: No Specific resident was compromised but, the facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you identify other patients that are at risk? No other patients are a risk as the sign was changed to reflect Caution: Oxidizing Gas (ES) Stored within No Smoking. Measure put in place: The facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you monitor? The Director of Plant Operations will be responsible to ensure that the signage is in place and reads Caution: Oxidizing Gas (ES) Stored within No Smoking. Any Variances will be brought to the QAPI Committee. 15/1/25 K923 Cylinder and Container Storage Identify patients that were at risk and what did: No Specific resident was compromised but, the facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you identify other patients that are at risk? No other patients are a risk as the sign was changed to reflect Caution: Oxidizing Gas (ES) Stored within No Smoking. Measure put in place: The facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you monitor? The Director of Plant Operations will be responsible to ensure that the signage is in place and reads Caution: Oxidizing Gas (ES) Stored within No Smoking. Any Variances will be brought to the QAPI Committee. 5/1/25
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control protocols, as evidenced by several observations and interviews. Staff were seen entering rooms of residents under contact and droplet precautions without wearing the appropriate personal protective equipment (PPE), such as gowns, gloves, and masks. This was particularly noted during the distribution of meal trays, which poses a risk of spreading communicable diseases. Additionally, there were instances of improper hygiene practices, such as double-gloving during care, which is against the facility's policy. Resident #57, who was admitted with an unspecified open wound, was found to have a care plan that included the use of an air mattress, offloading heels with pillows, and turning and repositioning every two hours. However, the care nurse reported that the resident was non-compliant with treatment and medications, which could potentially slow down the healing process. The resident was also on enhanced barrier precautions due to the open wound, yet the care provided did not fully align with the established protocols. Environmental issues were also noted, such as trash and food on the floor of the resident's pantry room, which is supposed to be cleaned by housekeeping staff. The soiled utility room door was found to be unable to lock, posing a security risk. Additionally, there were observations of oxygen tubing touching the floor, which could lead to contamination. These findings indicate a lack of adherence to the facility's infection control policies and procedures, contributing to the overall deficiency in maintaining a safe and sanitary environment.
Plan Of Correction
F 880 Ref F880 QAPI action Plan: Once identified by the surveyor, all staff that distribute meal service were reeducated on the process of Donning and Doffing when entering a room with droplet precautions. Once identified by the surveyor, resident #57 was assessed and is in stable condition. Regarding the staff member that double gloved, she was counseled for not following proper control procedures. Once identified by the surveyor, all staff were reeducated on the process of hygiene and also were provided individual education with acknowledgment. All staff were in-serviced on keeping the Common and the Pantry areas cleaned with no trash to be found on the floor, and this was done on [insert date]. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and are now being monitored randomly to ensure that the battery-operated lock system is working regularly. All shower rooms are the responsibility of any staff member that enters the shower room to take a resident into the shower room; there will be no cartons or food-related items nor masks in the shower room. Resident tubing touching the floor education was done on [insert date]. When a patient is on droplet precaution, we will do all possible to keep doors closed at all times. If the resident cannot comply due to mental state or is at risk, the team will care plan and possibly look for alternatives to include discharge. We will always try to mediate the issue for compliance with standards. We also have to honor the fact that this is their home and will work on reasonable accommodations. How will you identify other patients that are at risk: Initially, the management team created a QAPI from the initial exit with areas of concerns. We started immediate in-services since and changed systems and strengthened our quality assurance process and created all new tracking tools. Once the final 2567 came through, we updated the audits and worked on our plans as a team. The system was reevaluated by the QAPI Committee, and education was required for all staff since all residents were at risk as a facility-wide initiative. The following identified areas were used for education to staff and will be maintained on our QAPI for the remainder of the year for tracking and trending data: The following identified areas were used for education to staff: - F583-(N202) Personal Rights and Confidentiality - F-645 PASSAR Screening - F-656- (N054 and N072) Develop and implement Care Plans - F-761-(N095)- Label Drugs and Biologicals - F-842- Resident Records Identifiable Information - F-814 Dispose Garbage and Refuse Property - F-867- QAPI/QAA Improvement Activities - F-880- Control Plan - Proper techniques of Donning and Doffing - Droplet vs Enhanced Barrier Precaution - Meal tray distribution - Transmission Based Precautions - Hygiene - High Touch areas - Linen Handling Including clean and soiled - Cath Tubing not touching the floor Nursing focus will include: - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional System Response: Once identified by the surveyor, all staff that distribute meal service were reeducated on the process of Donning and Doffing when entering a room with droplet precautions. Once identified by the surveyor, resident #57 was assessed and is in stable condition. Regarding the staff member that double gloved, she was counseled for not following proper control procedures. Once identified by the surveyor, all staff were reeducated on the process of hygiene and also were provided individual education with acknowledgment. All staff were in-serviced on keeping the Common and the Pantry areas cleaned with no trash to be found on the floor, and this was done on [insert date]. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and are now being monitored randomly to ensure that the battery-operated lock system is working regularly. All shower rooms are the responsibility of any staff member that enters the shower room to take a resident into the shower room; there will be no cartons or food-related items nor masks in the shower room. When a patient is on droplet precaution, we will do all possible to keep doors closed at all times. If the resident cannot comply due to mental state or is at risk, the team will care plan and possibly look for alternatives to include discharge. We will always try to mediate the issue for compliance with standards. We also have to honor the fact that this is their home and will work on reasonable accommodations. Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. The following identified areas were used for education to staff: - F583-(N202) Personal Rights and Confidentiality - F-645 PASSAR Screening - F-656- (N054 and N072) Develop and Implement Care Plans - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional - K353 Tags Sprinkler System - K355- Tags- Sprinkler Regulations Maintenance and Testing - K 741 Smoking regulations - K-918 Essential Electrical Systems - K923 Cylinder and Container Storage How will you monitor: The Administrator and Director of Nursing will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #291 was observed with a floor mat on one side of the bed, but there was no care plan intervention for the use of floor mats. The MDS Coordinator confirmed that the floor mats had not been care planned until the day of the survey. Additionally, there were no physician orders for the floor mats, although the facility's policy did not require such orders. The lack of a comprehensive care plan for Resident #291's floor mat intervention was a clear deficiency. Resident #74 was observed with a floor mat on the right side of the bed, but the care plan did not initially reflect this intervention. The MDS Coordinator later revised the care plan to include the floor mat intervention, which had been implemented over the weekend. Despite the revision, the initial absence of a care plan for the floor mat intervention constituted a deficiency. The facility's policy allowed for the use of floor mats without a physician's order, but the care plan should have been updated to reflect the intervention. Resident #43 required a C-collar as per physician's orders, but there was no care plan for its use. Interviews with staff revealed that the resident was supposed to wear the C-collar constantly, but it was not always in place, and the resident was not compliant with wearing it during sleep or in the dining room. The C-collar was found in the laundry, wet and not ready for use. The absence of a care plan for the C-collar and the lack of consistent application of the physician's orders were significant deficiencies in the resident's care.
Plan Of Correction
N072-Comprehensive Care Plans Identify patients that were at risk and what did: Ref Resident #43 Regarding Resident #43 the brace with appropriate interventions was added to Care Plan. How will you identify other residents that are at risk: 100 % audit was completed to identify residents with brace. Any residents with brace were reviewed to ensure appropriate Care Plan was completed. Measures put in place: Upon admissions residents are assessed for devices. Any Devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During morning meeting the MDS Coordinator will update and validate to the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also training was completed on for care plan team members regarding Floor mats, C-Collar Devices and Following Physician Orders. Nursing staff to communicate and document anytime a resident refuses treatment such as the C-Collar to update care plan. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on assistive devices (brace and floor mats). How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse and or Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Regarding Resident #74 the Care Plan was completed with appropriate interventions to address. How will you identify other residents that are at risk: 100% audit was completed to identify residents at risk for and Care Plan with appropriate interventions. Measures put in place: Upon admissions residents are assessed for risk. Any residents at risk for a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on precautions and floor mats. How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Ref Resident #291 Regarding Resident #291 the Care Plan was completed with appropriate interventions to address floor mats. How will you identify other residents that are at risk: 100% audit was completed to identify residents with floor mats and Care Plan in place with appropriate interventions. Measures put in place: Upon admissions residents are assessed for floor mats. Any residents found to need a floor mat a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on floor mats. (risk for) How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications, as evidenced by several observations made by surveyors. In the West Wing medication storage room, a box containing multiple expired Covid-19 test kits was found. The Registered Nurse (RN) supervisor confirmed the expiration dates and removed the expired kits. The Director of Nursing (DON) later stated that the expired tests could still be used due to an extended expiration date listed on the FDA website, although the specific tests found expired were not covered by this extension. Additionally, an unlocked medication cart was observed on the West side nursing station. A Registered Nurse (RN) admitted to leaving the cart unlocked because they were in a hurry to assist residents. This action was contrary to the facility's policy, which requires medication carts to be locked when not in use to prevent unauthorized access. Furthermore, a surveyor observed a Registered Nurse (RN) leaving a resident's room with a cup of crushed medication and a lancet unattended. The RN left the room to retrieve an item needed for a procedure, leaving the medication and lancet accessible. The RN later stated that they left the items because the surveyor was present, although the proper protocol is to take medications and materials with them when leaving a room. The DON and Nursing Home Administrator were informed of this incident, and it was noted that the nurse was unaware that medications should not be left unattended.
Plan Of Correction
N095-FAC Drug Storage Identify patients that were at risk and what did: Once identified by surveyor the staff address of expired COVID Test, they were discarded. Central supply and Nursing managers educated immediately when identified by the surveyor and the Pharmacy consultant held a meeting with all nurses' about this topic on about expired medications and provided education. The nurse that left the medication cart unlocked was disciplined on Inservice with all nurses was done on to ensure compliance with Storage Biologicals Medications, Med Pass Administration and procedure by Pharmacist consultant. The DOH did a pharmacy audit on An. How will you identify other patents that are at risk: Medication Rooms and Medication Carts were checked for expired medications once identified by surveyor. DON and Nurse management checked med carts. The pharmacy was contacted to help with Med pass inservice and came to educate nurses on The Inservice included ensuring keeping carts locked when not in use and expired meds. Measures put in Place: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with Medication Administration sample. The supervisor form will be handed to DON for compliance tracking. In-service completed by Pharmacy consultant on for all nurses on expired medications and provided education. Training was also done by the Consultant pharmacist on regarding any expired testing kits and or medications. The inservice also included ensuring keeping carts locked when not in use. The DON Created new audit tolls called on -Medication Cart Audit -Treatment Cart Audit -Med room Audit. Investigator from the Florida Department of Health Division of Medical Quality Assurance conducted an inspection No findings. How will you monitor: The Pharmacist will conduct a monthly audit of all medications and Carts. Nursing staff will conduct weekly audit of all medication and carts. The DON Managers and Consultant Pharmacist will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, as required by professional standards and practices. The deficiency was identified when a Nurses' Progress Note inaccurately documented that the resident was COVID-19 positive and receiving treatment with a Z pack, despite the resident being COVID-19 negative and not receiving such medication. This discrepancy was confirmed through interviews with the Director of Nursing and a Licensed Practical Nurse, both of whom stated that the resident did not have COVID-19 and was not receiving the mentioned treatment. The resident in question had a severe mental status as indicated by a Brief Interview of Mental Status Summary Score of 00, requiring dependent assistance for activities of daily living. The resident's demographic sheet and Minimum Data Set Quarterly Assessment were reviewed, revealing diagnoses including protein-calorie malnutrition and atherosclerotic conditions. Despite these documented conditions, the medical records inaccurately reflected the resident's COVID-19 status and treatment, which could potentially affect the care provided. The facility's policies on charting and documentation, as well as charting errors and omissions, were reviewed. These policies require that all services and changes in a resident's condition be accurately documented by licensed personnel. However, the inaccurate entry in the resident's medical record was not corrected, highlighting a failure to adhere to these policies. This inaccuracy in medical records has the potential to impact the care of any resident within the facility.
Plan Of Correction
N101-FAC Resident Medical Records Identify patients that were at risk and what did: Once identified by surveyor regarding Resident #33, the Director of Nursing contacted the LPN that erroneously documented that the patient was COVID positive when he was not and was asked to clarify the note. This was done on How will you identify other patients that are at risk: The LPN received a 1:1 training on Accurate Documentation. An audit was done on all remaining residents with diagnosis to ensure that the documentation was correct. Measures put in Place: An inservice was done for all Nurses on Resident Records - Identifiable Information and Resident Accuracy was started for all nurses on an ongoing basis. Example of Error identified was presented and discussed. Thereafter, the DON has an ongoing QAPI Plan for incorrect documentation Audit Tool. This was started on a weekly review. How will you monitor: The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Tripping Hazard Due to Improperly Secured Electrical Cord
Penalty
Summary
The facility failed to maintain a safe environment for its residents, as evidenced by an observation of an electrical cord creating a tripping hazard in a resident's room. The cord, which was connected to an air mattress, was wrapped around a side table and suspended in the air, posing a risk of tripping. This observation was made in the presence of a registered nurse, who was informed of the hazard by the surveyor. The resident involved had a history of acute failure and COVID-19, and was dependent on staff for transfers. The resident's care plan indicated a risk related to monoplegia of the right dominant side, and interventions were in place to follow facility protocol. Despite these measures, the tripping hazard was not addressed until it was pointed out by the surveyor. The facility's policy on safety and supervision emphasizes the importance of maintaining an environment free from accident hazards. Employees are expected to be trained to identify and report potential hazards. However, the presence of the tripping hazard suggests a lapse in adherence to these policies, as the electrical safety risk was not mitigated until after the surveyor's intervention.
Plan Of Correction
N0110-Physical Environmental-Safe Clean, Homelike Identify patients that were at risk and what did: Patient #2 bed cord was identified by surveyor and told Administrator; the director of plant operations was instructed to tie all the to the frame to be removed from any potential trip hazard. Thereafter, a full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety on. How will you identify other patients that are at risk: A full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety. Staff were also inserviced on to discuss the risk of tripping hazards. Measures put in Place: On and Staff were inserviced on all risk and precautions and safety measures that required. Upon admission, resident rooms are assessed for room safety. The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with any potential trip hazards such as any electronic charging devices. We have also added to our Gang Tackling Quality programs where scheduled rooms are checked monthly to ensure that any findings out normal are addressed immediately and reported to Management. The Forms are part of Housekeeping and Maintenance department QAPI Tracking. Training occurred on staff were also provided with 6-point training on overall safety hazards and the risk associated. The supervisor form will be handed to DON for compliance tracking. How will you monitor: The DON /Maintenance and Housekeeping Supervisors will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inadequate Monitoring of Tubing Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident, as evidenced by observations of the tubing being kinked and touching the floor. The resident was observed in bed with a system in progress at 2 liters per minute, and no apparent distress was noted. However, the tubing was observed to be kinked in a circle and not properly draining. A Registered Nurse (RN) was present and was notified about the kinking, after which the RN straightened the tubing to allow free flow. The RN mentioned that they round every morning to check the tubing, but did not notice the kink due to the night nurse working with the system. Further observations revealed the tubing touching the floor, which was attributed to the bed being lowered too low. A Licensed Practical Nurse (LPN) stated that they round every two hours and communicate with the Certified Nursing Assistant (CNA) about required interventions. The CNA confirmed receiving in-services on care and stated that they ensure the collection bag does not touch the floor and is anchored to the bed. Despite these measures, the tubing was found touching the ground, indicating a lapse in monitoring and intervention. The resident had a significant change in status, with a diagnosis that included neuropathic conditions. The care plan for the resident included checking tubing for kinks and ensuring proper drainage. However, there was confusion among staff regarding the type of system in place, as the LPN was unaware of a change from one system to another. The Director of Nursing (DON) acknowledged the need for staff to monitor the system to ensure proper drainage and prevent tubing from touching the floor. The physician orders were updated to reflect the correct system in use.
Plan Of Correction
Identify patients that were at risk and what did: Once identified by surveyor, the staff addressed the issue for resident #2, the tubing being kinked and tubing touching the floor. Thereafter, a full house audit was completed after surveyors identified the issues of cath care and rooms were checked for compliance. All rooms were checked for safety. All nurses and CNAs were educated on control and the difference between super pubic and regular. How will you identify other patients that are at risk: Thereafter, a full house audit was completed after surveyors identified the issues of care and rooms were checked for compliance. All rooms were checked for safety. All nurses and CNAs were educated on control and the difference between super pubic and regular. Measures put in place: A clinical inservice was held to discuss care. The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with safety as far as positioning and ensuring that it is not touching the floor. Additionally, the supervisor form will be handed to the DON for compliance tracking. The DON created a care random audit observations checklist. How will you monitor: The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Privacy Breach Due to Unattended Computer Screens
Penalty
Summary
The facility failed to ensure the privacy of residents' information, as evidenced by observations of unlocked and unattended computer screens displaying resident information. On two separate occasions, surveyors observed computer screens left unlocked and unattended, with resident information visible. The first incident occurred at the East side medication cart, where a Registered Nurse (RN) left the screen unlocked while attending to other duties. The RN acknowledged the oversight, attributing it to being preoccupied with finding a supervisor for the surveyor. The second incident was observed at the East side nursing station, where another computer screen was left unlocked and unattended, displaying resident information. A Licensed Practical Nurse (LPN) was informed of the situation by the surveyor and promptly locked the screen, indicating that another staff member had left it open. These observations highlight a breach in the facility's policy to protect patient privacy and confidentiality, as outlined in their Patient Privacy Policy. The facility's policy mandates that all patient information be treated as confidential and that unauthorized access, use, or disclosure is prohibited. It requires that electronic records be stored in password-protected systems with encryption to prevent unauthorized access. The policy applies to all employees, contractors, volunteers, and other personnel working in the nursing home, emphasizing the importance of safeguarding personal, medical, and financial information of residents.
Plan Of Correction
This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. N202 Right to Privacy Identify patients that were at risk and what did: Immediately, once identified by the surveyor, all Department managers were notified and asked to meet with their staff and go over HIPAA and protection of patient privacy. A facility-wide in-service was held on through /2025 that reviewed HIPAA privacy and all staff were started on individual HIPAA training. The assessment completed included the issue, Root Cause Analysis, and Performance Improvement Plan. Staff were trained on specific education related to HIPAA with acknowledgement forms. Regarding the Nurse that left the computer unattended at the med cart, they were counseled on the importance of HIPAA and protecting privacy; counseling was completed on. How will you identify other patients that are at risk? A full house audit was completed on , to determine that no other privacy screens were being left unattended by not only nurses but staff that use the tablets for documentation as well. Staff and Managers were reminded of HIPAA Policy, and Department managers were tasked to keep vigilant about any screens with patient information being left unattended. Thereafter, the DON created the Audit checklist to spot check for computer security during use. Measure put in place: A facility-wide in-service was held on and /2025 that reviewed HIPAA privacy and all staff were started on individual HIPAA training. The assessment completed included the issue, Root Cause Analysis, and Performance Improvement Plan. Staff were trained on specific education related to HIPAA with acknowledgement forms. Training will continue upon hire and annual review. A new system tool has been created whereby the Nurse manager that covers 24 hours per day has a form that was developed and included the surveillance of HIPAA Compliance with all electronics including computers and tablets. The DON created an audit checklist which will be located at the Nurses' desk and is a daily spot check for computer security during use. All department heads are also required to monitor for the same on their daily rounds and when finding any non-compliant staff, to report to managers and provide ongoing education and progressive discipline if rules are not adhered to. We posted a sign at the nurses' station and on med carts as a reminder to lock screens before leaving long-term prevention through inclusion and annual training and orientation. How will you monitor? The DON and all department heads are also required to use the form to track compliance. The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur daily for 30 days, then monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Privacy Breach of Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as required by federal regulations. During a survey, it was observed that two out of four computer screens on the East side nursing station were left unlocked and unattended, displaying resident information. This breach of privacy was noted on the East side medication cart #1 and at the East side nursing station, where resident information was easily accessible and visible to unauthorized individuals. At 7:39 AM, a surveyor observed an unlocked, unattended computer screen on the East side medication cart #1. The Registered Nurse (RN) responsible for the cart returned at 7:41 AM and acknowledged the protocol breach, stating that they forgot to lock the screen due to being preoccupied with finding a supervisor for the surveyor. Similarly, at 8:08 AM, another unlocked, unattended computer screen was observed at the East side nursing station. A Licensed Practical Nurse (LPN) was informed of the situation at 8:09 AM and immediately locked the screen, indicating that another staff member had left it open. The facility's policy on patient privacy, which aligns with the Health Insurance Portability and Accountability Act (HIPAA) and state-specific regulations, mandates that all patient information be treated as confidential. Unauthorized access, use, or disclosure of patient information is prohibited, and access to such information should be restricted to authorized personnel only. Despite these policies, the facility failed to adhere to the required standards, resulting in a deficiency in maintaining the privacy and confidentiality of residents' information.
Plan Of Correction
This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. F583 Personal Rights and Confidentiality Identify patients that were at risk and what did: Immediately, once identified by the surveyor, all Department managers were notified and asked to meet with their staff and go over HIPPA and protection of patient privacy. A facility wide Inservice was held on through /2025 that reviewed HIPPA privacy and all staff were started on individual HIPPA training. The assessment completed included the issue, Root Cause Analysis and Performance improvement Plan, Staff Were trained on specific Education related to HIPPA with acknowledgement forms. Regarding the Nurse that left the computer unattended at med cart was counseled on the importance of HIPPA and protecting privacy, counseling was completed on. How will you identify other patents that are at risk? A full house audit was completed on, to determine that no other Privacy screens were being left unattended by not only nurses but staff that use the tablets for documentation as well. Staff and Managers were reminded of HIPPA Policy and Department managers were tasked to keep vigilant about any screens with patient information being left unattended. Thereafter the DON created the Audit checklist to spot check for computer security during use. Measure put in place: A facility wide Inservice was held on and /2025 that reviewed HIPPA privacy and all staff were started on individual HIPPA training. The assessment completed included the issue, Root Cause Analysis and Performance improvement Plan. Staff Were trained on specific Education related to HIPPA with acknowledgement forms. Training will continue upon Hire and annual review. A new system tool has been created whereby the Nurse manager that covers 24 hrs per day has a form that was developed and included the surveillance of HIPPA Compliance with all electronics including computers and tablets. The DON created an audit checklist which will be located at Nurses desk and is a daily spot checks for computer security during use. All department heads are also required to monitor for the same on their daily rounds and when finding any non-compliant staff, to report to managers and provide ongoing education and progressive discipline if rules are not adhered to. We posted a sign at nurses' station and on med carts as a reminder to Lock screens before leaving long term prevention through inclusion and annual training and Orientation. How will you monitor? The DON and All department Heads are also required will use the form to track compliance. The DON and or designee will be responsible for bringing the finding and summary to the QAPI Committee. This will occur daily for 30 days, then Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inaccurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately prior to admission for three residents. The PASARR Level I screenings for these residents were either incomplete or incorrect, failing to reflect the residents' current diagnoses and medication needs. This deficiency was identified during a survey, which included observations, record reviews, and interviews with facility staff. Resident #50 was admitted with certain diagnoses, but the PASARR Level I did not include these diagnoses, and no PASARR Level II was deemed necessary. The Minimum Data Set (MDS) assessment indicated severe mental status issues, yet the PASARR did not reflect this, leading to a discrepancy in the resident's care needs. Interviews with the Admissions Director and Director of Nursing (DON) confirmed that the PASARR was incorrect and should have included the relevant diagnoses. Similarly, Resident #83's PASARR Level I was completed without acknowledging the resident's acute failure and affective disorder diagnoses. The MDS assessment showed severe mental status issues, but the PASARR did not require a Level II review. The DON acknowledged the oversight, stating that the PASARR should have included the diagnoses. Resident #60 also had an incomplete PASARR, which did not reflect the resident's known condition and aggressive behaviors. The DON admitted that the PASARR should have been updated to reflect the resident's current mental illness diagnoses and medication needs.
Plan Of Correction
PASARR screening for MD and ID Identify patients that were at risk and what did: Patients #50, 83 & 60 were reassessed in the PASSAR. Resident #50 was discharged on home with Daughter. Patients #83 and #60 remain in the facility. PASARS were reevaluated to reflect proper diagnosis, and PASARR resident review screening was requested. This was completed on for resident #83. Ref #60 the resident review was completed on. A full house audit was completed identified the issues, all residents PASSARS were reviewed for accuracy. How will you identify other patents that are at risk: On a QAPI Meeting occurred to review the PASSAR and provided education to the committee. A full house audit was completed identified the issues, all residents PASSARS were reviewed for accuracy. The consistency of the audit was to make the PASSARES Level 1 and 2 are accurate and in place. Any updates were made and being made during the course of the audit. Measures put in Place: The facility admissions team will work with local hospitals to ensure prior to admission, that the screening uses the PASSAR criteria. Admissions Director and Director of Nursing as well Social Service were provided the PASSAR education on. The Director of Nursing and admissions will review all new admissions during the week, to ensure accuracy during morning meeting and on weekend a nursing supervisor will review for accuracy and compliance, and if patient was readmitted to compare with prior PASSAR to ensure if any new changes have occurred. Additionally, the Social Service Department and Nursing will also address when Physician changes orders for medications, then the PASSAR will be reviewed and updated if necessary. The MDS Department will also be part of reevaluating during the quarterly assessments. Additionally, as of a QAPI tool was developed as part of Pre-Admission Screening & Resident Review (PASARR) Audit was implemented and will be done upon admission and Gang Tackling, which is the facilities continuous quality improvement program Monthly Review. How will you monitor: The Administrator/ Nursing Management team and or Designee will review all admissions for compliance and keep a running list for QAPI. Pre-Admission Screening & Resident Review (PASSAR) Audit will be done upon admission and Gang Tackling Monthly Review. The Admissions Director and Director of Nursing and or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident was observed with a floor mat on the right side of their bed, but there was no comprehensive care plan with interventions for the use of floor mats. The MDS Coordinator confirmed that the floor mats had not been care planned until the day of the survey. Additionally, there were no current physician orders for floor mats for this resident, indicating a lack of proper documentation and planning. Another resident was observed with a floor mat on the right side of their bed, but the care plan did not reflect the correct intervention until it was revised on the day of the survey. The resident was under precautions, and the floor mat was used for safety, but the care plan was not updated to reflect this intervention until after the surveyor's inquiry. The Restorative nurse communicated the need for floor mats to the MDS Coordinator, but the care plan was not updated in a timely manner. A third resident required a C-collar as per physician's orders, but there was no care plan for its use. The resident was supposed to wear the C-collar constantly, but staff reported that the resident did not like to wear it while sleeping or in the dining room. The C-collar was found in the laundry, wet and not in use, indicating a failure to follow physician's orders and ensure the resident's safety. The facility's policy required that physician orders be followed as prescribed, but this was not adhered to in this case.
Plan Of Correction
Develop implement Comprehensive Care Plan Identify patients that were at risk and what did: Ref Resident #43 Regarding Resident #43 the brace with appropriate interventions was added to Care Plan. How will you identify other residents that are at risk: 100 % audit was completed to identify residents with brace. Any residents with brace were reviewed to ensure appropriate Care Plan was completed. Measures put in place: Upon admissions residents are assessed for devices. Any Devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During morning meeting the MDS Coordinator will update and validate to the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also training was completed on for care plan team members regarding Floor mats, C- Collar Devices and Following Physician Orders. Nursing staff to communicate and document anytime a resident refuses treatment such as the C-Collar to update care plan. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on assistive devices (brace and floor mats). How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse and or Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Ref Resident #74 Regarding Resident #74 the Care Plan was completed with appropriate interventions to address. How will you identify other residents that are at risk: 100 % audit was completed to identify residents at risk for and Care Plan with appropriate interventions. Measures put in place: Upon admissions residents are assessed for risk. Any residents at risk for a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on precautions and floor mats. How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Ref Resident #291 Regarding Resident #291 the Care Plan was completed with appropriate interventions to address floor mats. How will you identify other residents that are at risk: 100% audit was completed to identify residents with floor mats and Care Plan in place with appropriate interventions. Measures put in place: Upon admissions residents are assessed for floor mats. Any residents found to need a floor mat a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on floor mats, (risk for). How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Tripping Hazard Due to Improper Electrical Cord Management
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not adequately managing an electrical cord, which created a tripping hazard. During an observation, it was noted that an electrical cord for an air mattress was wrapped around a side table and suspended in the air, posing a risk of tripping in the resident's room. A registered nurse was present during the observation and was informed of the hazard by the surveyor. The nurse then readjusted the plug behind the bed. The resident involved had a history of acute failure and COVID-19, and was dependent on staff for transfers due to monoplegia of the right dominant side. The resident's care plan indicated a risk related to their condition, and interventions were in place to follow facility protocol. The facility's policy emphasized making the environment as free from accident hazards as possible, with a focus on resident safety and supervision. However, the presence of the tripping hazard indicated a lapse in adhering to these safety protocols.
Plan Of Correction
F-689 Free of Hazards / Supervision/Devices Identify patients that were at risk and what did: Patient #2 bed cord was identified by surveyor and told Administrator; the director of plant operations was instructed to tie all the to the frame to be removed from any potential trip hazard. Thereafter, a full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety on. How will you identify other patients that are at risk: A full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety. Staff were also inserviced on to discuss the risk of tripping hazards. Measures put in place: Staff were inserviced on all risk and precautions and safety measures that required. Upon admission, resident rooms are assessed for room safety. The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with any potential trip hazards such as any electronic charging devices. We have also added to our Gang Tackling Quality programs where scheduled rooms are checked monthly to ensure that any findings out normal are addressed immediately and reported to Management. The forms are part of Housekeeping and Maintenance department QAPI Tracking. Training occurred on staff were also provided with 6-point training on overall safety hazards and the risk associated. The supervisor form will be handed to DON for compliance tracking. How will you monitor: The DON/Maintenance and Housekeeping Supervisors will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Deficiency in Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a catheter, as evidenced by observations of the tubing being kinked and touching the floor. During the survey, Resident #2 was observed in bed with oxygen in progress at 2 liters per minute via a nasal cannula, and no apparent distress was noted. However, the catheter tubing was observed to be kinked in a circle and not properly draining. A Registered Nurse (RN) present in the room was notified by the surveyor about the kinking of the tubing, and the RN then straightened out the tubing to allow free flow. The RN stated that they round every morning to check the tubing, but on this occasion, they did not notice it was kinked. Further observations revealed that the catheter tubing was touching the floor. A Licensed Practical Nurse (LPN) stated that the tubing was not touching the floor during their rounds and suggested that the bed being lowered too low might have caused the tubing to touch the floor. The LPN rounds every two hours and communicates with the Certified Nursing Assistant (CNA) about required interventions for care. The CNA confirmed receiving in-services on catheter care and stated that they ensure the collection bag does not touch the floor and is anchored to the bed. Despite these measures, the tubing was found touching the ground, indicating a lapse in maintaining proper catheter care. The Director of Nursing (DON) was made aware of the concerns and stated that staff are to monitor the catheter to ensure it is draining properly and that the tubing is not kinked or touching the floor. The physician orders for Resident #2's care were found to be outdated, as they did not reflect the current catheter in use. The facility's policy on catheter care emphasizes securing and checking drainage tubing and bags to prevent urinary tract infections, but the observations during the survey indicated non-compliance with these procedures.
Plan Of Correction
Identify patients that were at risk and what did: Regarding Resident #2, the drainage tubing was immediately changed, and the bed was raised. The assigned Nurse and C.N.A were immediately in-serviced on control protocol and the difference between Super pubic and regular. Identify patients that were at risk and what did: A 100% audit was completed to identify residents with care and/or to ensure bags are not kinked and not touching the floor. All nurses and CNAs were educated on control protocol and the difference between Super pubic and regular. Measures put in Place: A clinical in-service was held for all nursing staff to discuss care and control protocol. How will you monitor: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with safety as far as positioning and ensuring that it is not touching the floor. Additionally, the supervisor form will be handed to the DON for compliance tracking. The DON created a care random audit observations checklist. The random audit will be done daily. Continuous in-service on the care of residents with super pubic and needed will be done monthly and as needed.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly store medications, as evidenced by several observations made during a survey. In the West Wing medication storage room, a box containing multiple expired Covid-19 test kits was found. Staff S, a Registered Nurse supervisor, confirmed the expiration dates and removed the expired kits. Despite the Director of Nursing (DON) stating that the expired tests could still be used due to an extended expiration date listed on the FDA website, the presence of expired items in the storage room indicates a lapse in the facility's protocol for monitoring and removing expired supplies. Additionally, an unlocked medication cart was observed on the West side nursing station. Staff U, an RN, acknowledged that the cart should have been locked when unattended but admitted to forgetting due to being in a hurry to assist residents. This oversight highlights a failure to adhere to the facility's policy that requires medication carts to be locked when not in use, ensuring that medications are not accessible to unauthorized individuals. Furthermore, in the room of a resident, Staff H, an RN, left a cup of crushed medication mixed in water and a lancet unattended while retrieving an item to assist with a procedure. Staff H later explained that the presence of the surveyor led to the oversight, but acknowledged that the proper protocol is to take medications and materials when leaving a resident's room. This incident underscores a breach in the facility's policy for safe and secure medication storage and handling, as medications should not be left unattended to prevent potential misuse or errors.
Plan Of Correction
Identify patients that were at risk and what did: Once identified by surveyor the staff address of expired COVID Test, they were discarded. Central supply and Nursing managers educated immediately when identified by the surveyor and the Pharmacy consultant held a meeting with all nurses' about this topic on about expired medications and provided education. The nurse that left the medication cart unlocked was disciplined on. An Inservice with all nurses was done on to ensure compliance with Storage Biologicals Medications, Med Pass Administration and procedure by Pharmacist consultant. The DOH did a pharmacy audit on. How will you identify other patents that are at risk: Medication Rooms and Medication Carts were checked for expired medications once identified by surveyor. DON and Nurse management checked med carts. The pharmacy was contacted to help with Med pass Inservice and came to educate nurses on. The Inservice included ensuring keeping carts locked when not in use and expired meds. Measures put in Place: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with Medication Administration sample. The supervisor form will be handed to DON for compliance tracking. In-service completed by Pharmacy consultant on for all nurses on expired medications and provided education. Training was also done by the Consultant pharmacist on regarding any expired testing kits and or medications. The inservice also included ensuring keeping carts locked when not in use. The DON Created new audit tolls called on: - Medication Cart Audit - Treatment Cart Audit - Med room Audit Investigator from the Florida Department of Health Division of Medical Quality Assurance conducted an inspection. No findings. How will you monitor: The Pharmacist will conduct a monthly audit of all medications and Carts. Nursing staff will conduct weekly audit of all medication and carts. The DON Managers and Consultant Pharmacist will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Improper Disposal of Cardboard Boxes
Penalty
Summary
The facility failed to properly dispose of cardboard boxes, as observed outside the kitchen door. The facility's policy requires that food storage boxes and containers be disposed of by the end of each shift into the outside dumpsters. However, during an observation at 7:01 AM, multiple cardboard boxes were found scattered on the ground and not contained in the garbage bin. This was confirmed by photographic evidence. Interviews with staff further highlighted the deficiency. A Dietary Aide stated that someone is responsible for breaking down the cardboard boxes and taking them to the garbage container, indicating that the boxes should not be left on the ground. The Dietary Director also confirmed that the cardboard boxes were removed from the ground outside the kitchen door and acknowledged that they should not have been there.
Plan Of Correction
F-814 Dispose Garbage and Refuse property: Identify patients that were at risk and what did: Once identified by surveyor with multiple cardboard boxes on the ground and not contained in the garbage bin. The Certified Dietary manager and Registered Dietician met with staff on and to ensure that the empty cardboard boxes were no longer allowed to be left unattended and not broken down and discarded. No residents were placed at risk. How will you identify other patents that are at risk: Once identified by surveyor with multiple cardboard boxes on the ground and not contained in the garbage bin. The Certified Dietary manager and Registered Dietician met with staff on and to ensure that the empty cardboard boxes were no longer allowed to be left unattended and not broken down and discarded. No residents were placed at risk. Measures put in Place: The CDM/RD or designee created a QAPI spot check form and created a new process to Discard cardboard boxes by dietary staff. This Inservice was completed on and Additionally, a Cardboard only bin was placed on the outside of building as a general cardboard disposal location. Ali other non-dietary boxes were also detailed to be broken down and discarded in a main garbage container. How will you monitor: The CDM /RD or designee will be responsible for bringing the findings or progress to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, as evidenced by a discrepancy in the Nurses' Progress Note. The note inaccurately documented that the resident was COVID-19 positive and receiving treatment with a Z pack, while in reality, the resident was COVID-19 negative and not receiving such medication. This inaccuracy was confirmed during interviews with the Director of Nursing and a Licensed Practical Nurse, who both stated that the resident did not have COVID-19 and was not on the mentioned medication. The facility's Charting and Documentation Policy requires that all services provided to residents and any changes in their medical or mental condition be accurately documented in their medical records. However, the review of the resident's records revealed a failure to adhere to this policy, as the progress note contained incorrect information about the resident's COVID-19 status and treatment. This error was not corrected in the medical record, which is a violation of the facility's policy on maintaining accurate medical records. The resident involved had a severe cognitive impairment, as indicated by a Brief Interview of Mental Status score of 00, and required dependent assistance for activities of daily living. The inaccurate documentation in the resident's medical record has the potential to affect the care and treatment provided to the resident, as well as other residents in the facility, by leading to inappropriate precautions or treatments based on incorrect information.
Plan Of Correction
F-842 Resident Records- identifiable Information Identify patients that were at risk and what did: Once identified by surveyor regarding Resident #33, the Director of Nursing contacted the LPN that erroneously documented that the patient was COVID positive when he was not and was asked to clarify the note. This was done on How will you identify other patents that are at risk: The LPN received a 1:1 training on Accurate Documentation. An audit was done on all remaining residents with diagnosis to ensure that the documentation was correct. Measures put in Place: An inservice was done for all Nurses on Resident Records- Identifiable information and Resident Accuracy was started for all nurses on and ongoing. Example of Error identified was presented and discussed. Thereafter, DON has an ongoing QAPI Plan for incorrect documentation Audit Tool. This was started on as a weekly review. How will you monitor: The DON and or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Repeated Deficiencies in Infection Control Protocols
Penalty
Summary
The facility failed to implement effective plans of action to address quality deficiencies related to infection prevention and control protocols. Specifically, the facility did not follow control protocols in the east side soiled utility room and failed to implement hygiene protocols for a resident. This deficiency was identified during a recertification survey, where it was noted that the facility had previously been cited for similar issues. The survey history revealed that during a previous recertification survey, the facility was cited for failing to implement control procedures for three residents out of a sample of 28. This indicates a repeated pattern of deficient practices in infection prevention and control, which the facility has not adequately addressed. The Director of Nursing confirmed that the facility holds monthly Quality Assurance and Performance Improvement (QAPI) meetings, involving various department heads, to review deficiencies and track corrective actions. Despite these meetings and efforts to monitor quality assurance, the facility's actions have not been effective in preventing repeated deficiencies. The failure to follow established protocols in the soiled utility room and for the resident's hygiene suggests a lack of systematic implementation and monitoring of infection control measures. This ongoing issue affects the facility's ability to provide safe and effective care to its residents.
Plan Of Correction
F-867 QAPI/QAA Improvement Activities Identify patients that were at risk and what did: Initially, the management team created a QAPI from the initial exit with areas of concerns. We started immediate in-services since and changed systems and strengthened our quality assurance process and created all new tracking tools. Once the final 2567 came through, we updated the audits and worked on our plans as a team. Ref F880 QAPI action Plan: Once identified by the surveyor, all staff that distribute meal service were reeducated on the process of Donning and Doffing when entering a room with droplet precautions. Once identified by the surveyor, resident #57 was assessed and is in stable condition. Regarding the staff member that double gloved, she was counseled on not following proper control procedures. Once identified by the surveyor, all staff were reeducated on the process of hygiene and also were provided individual education with acknowledgment. All staff were in-serviced on keeping the Common and the Pantry areas cleaned with no trash to be found on the floor, and this was done on. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and is now monitoring randomly to ensure that the battery-operated lock system is working regularly. All shower rooms are the responsibility of any staff member that enters the shower room to take a resident into the shower room; there will be no cartons or food-related permits nor masks in the shower room. Resident tubing touching the floor education was done on. When a patient is on droplet precaution, we will do all possible to keep doors closed at all times. If the resident cannot comply due to mental state or is at risk, the team will care plan and possibly look for alternatives to include discharge. We will always try to mediate the issue for compliance with standards. We also have to honor the fact that this is their home and will work on reasonable accommodations. How will you identify other patients that are at risk: Ref F880 QAPI action Plan: Besides the care nurse, all staff were re-educated on control procedures on (25). Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. Measures put in Place: Besides the care nurse, all staff were re-educated on control procedures on (25). Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. The following identified areas were used for education to staff and will be maintained on our QAPI for the remainder of the year for tracking and trending data: F583-(N202) Personal Rights and Confidentiality F-645 PASSAR Screening F-656- (N054 and N072) Develop and Implement Care Plans F-761-(N095)- Label Drugs and Biologicals F-842- Resident Records Identifiable Information F-814 Dispose Garbage and Refuse Property F-867- QAPI/ QAA Improvement Activities F-880- Control Control Plan - Proper techniques of Donning and Doffing - Droplet vs Enhanced Barrier Precaution - Meal tray distribution - Transmission Based Precautions Hygiene - High Touch areas - Linen Handling including clean and soiled - Cath Tubing not touching the floor Nursing focus will include: - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional How will you monitor: The Administrator and Director of Nursing will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing. Since QAPI was identified as needing improvement, we have changed the reporting and all citations will have a structured monitoring designated by accountable reporting, trending, analysis, and follow-through.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to maintain accurate Minimum Data Set (MDS) records for two residents, leading to deficiencies in their care plans. Resident #24 was incorrectly coded as a hospice resident in the MDS, despite having no hospice orders in their medical records. This discrepancy indicates a lack of accurate documentation and communication within the facility regarding the resident's care status. The resident's medical history included surgical aftercare, but there was no care plan related to hospice, highlighting a significant oversight in the resident's care documentation. Similarly, Resident #89 was inaccurately coded in the MDS as having a planned return to a short-term general hospital, although the resident was actually discharged to an Assisted Living Facility (ALF). The medical records and physician's orders confirmed the discharge to an ALF, yet the MDS did not reflect this change. This error suggests a failure in updating the resident's discharge status accurately, which is crucial for ensuring continuity of care and appropriate resource allocation. Interviews with the MDS Coordinator revealed that there was an oversight error in the communication process between departments, including nursing, social services, and billing. The coordinator acknowledged the need for modifications to correct these inaccuracies. The facility's policy requires timely and appropriate resident assessments, but the errors in the MDS coding for these two residents indicate a lapse in adherence to these procedures, resulting in the noted deficiencies.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to maintain accurate Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their documented care needs and discharge plans. Resident #24 was incorrectly coded as a hospice resident in the MDS, despite having no hospice orders in their medical records. This resident was admitted for surgical aftercare, and the MDS inaccurately reflected their status, as there was no care plan related to hospice. Similarly, Resident #89 was inaccurately coded in the MDS as having a planned return to a short-term general hospital, while their medical records indicated a discharge to an Assisted Living Facility (ALF). The care plan for Resident #89 supported discharge to an ALF, with interventions for transportation and post-discharge care planning. The inaccuracies in the MDS assessments were attributed to oversight errors by the MDS Coordinator, who acknowledged the need for modifications to correct these errors. The facility's policy requires timely and appropriate resident assessments, but the discrepancies in the MDS coding for these residents indicate a failure to adhere to these requirements. The MDS Coordinator stated that communication with nursing, social services, and billing departments occurs to clarify discharge plans, but these processes did not prevent the errors in the residents' MDS documentation.
Failure to Implement Restorative Care Plan for C-Collar Use
Penalty
Summary
The facility failed to create and implement a Restorative Care Plan for a resident who had a physician's order to wear a C-collar at all times. Observations revealed that the resident was often found lying in bed without the C-collar, and there was no care plan in place for its use. The resident was observed at different times of the day, appearing tired and disoriented, but without visible signs of distress or discomfort. The resident's medical records indicated a diagnosis that required the use of a C-collar, with specific instructions to keep it in place at all times, except during care, and to inspect the skin for abnormalities every shift. However, interviews with staff revealed inconsistencies in following these orders. A Registered Nurse acknowledged the requirement for the C-collar to be worn constantly, while a Restorative Certified Nursing Assistant noted that the resident often did not like to wear it while sleeping or in the dining room. The C-collar was found to be in the laundry, wet, and not available for immediate use. The Director of Nursing confirmed that staff monitored the resident every two hours and mentioned the resident's participation in a prevention program. Despite this, there was no new order received for the removal of the C-collar after a CT scan was conducted. The facility's policy requires that physician orders be followed as prescribed, and any deviations must be documented in the resident's medical records, which was not done in this case.
Plan Of Correction
Identify patients that were at risk and what did: Patient #43. Care plans were updated accordingly, and different interventions were made. Regarding Resident #43, the brace was added to the care plan. All other residents with similar devices were also identified and care plans verified. How will you identify other patients that are at risk: Regarding Resident #43, the brace was added to the care plan. All other residents with similar devices were also identified and care plans. (Audit Tool) Measures put in Place: Upon admissions, residents are assessed for devices. Any devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During the morning meeting, the MDS Coordinator will update and validate the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also, training was completed for care plan team members regarding floor mats, C-Collars, devices, and following physician orders, and nursing to communicate anytime a resident refuses treatment such as the C-Collar. This will be reported and presented to the QAPI committee to ensure compliance. How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse, and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 317 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Azure Shores Rehab | 0.1 mi | ★★★★★ | 13 | 0 |
| Shoreside Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Hialeah Shores Nursing And Rehab Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Miami Jewish Health Systems, Inc | 2.8 mi | ★★★★★ | 5 | 0 |
| Pines Nursing Home | 2.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.