Terrace Of Hialeah, The

F-F645 PASRR Screening for Mental Diagnosis (MD) and Intellectual Disability (ID),

F-F689 Free of Accidents and Hazards. The facility was cited for

F-F755 in 2023. These repeated deficient practices have the potential to affect any of the 231 residents residing in the facility at the time of the survey.

The findings included:

Record review of the facility policy and procedure title Quality Assurance Performance Improvement (QAPI) Program, implemented November 2012, revised November 2023 indicate: The purpose of the QAPI program is to ensure the organization has an organized quality assessment and improvement process program that includes performance measurement, performance assessment and performance improvement and addresses the care and unique services provided by the facility.

Guidelines and Standards

In accordance with the direction of the board of directors, the Quality assurance Committee will establish a planned, systemic organization wide approach to design processes, measurements, assessments, and improve, organization performance and assure that:

Activities are collaborative and the interdisciplinary team, including input from direct care staff, other staff, residents and residents' representatives.

Data is systematically collected.

Appropriate statistical technique is maintained.

Data about its processes or outcomes is maintained.

Staff are provided with education concerning the approaches and methods of quality improvement, and are trained in reporting, assessing and improving processes that contribute to improving resident outcomes.

Expectations for the committee I terms of functions, reporting methods and appropriateness of systems used to facilitate the collection, management, and analysis of date needed for quality improvement are established.

Specific quality assurance measures will be identified to be measured on a continuing basis

Committee procedures include analyzing and evaluating the effectiveness of the committee's contribution to improving quality

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 105803 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105803 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Committee ensures collected of data on important process or outcomes related to resident care and organization functions. Level of Harm - Minimal harm or potential for actual harm Adequate resources for assessing and improving the organization's governance, managerial, clinical and support processes are allocated. This includes assignment of personnel and adequate time to participate. In Residents Affected - Few addition, information system and data management processes are provided to support ongoing performance improvement activities.

Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 03/29/24, 04/29/24, and 05/29/24 documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist/Risk Manager, Dietary Manager, Clinical Dietician, Director of Housekeeping, Director of Maintenance, Director of therapy, Director of Human resources, Director of admissions, director of Business office, Director of Social Services, Director of Activities, MDS (Minimum Data Set) Coordinator, and Consultant Pharmacist.

During an interview with the Director of Nursing/Quality Assurance (QA), Administrator/QA on 06/27/2024 at 3:24 PM. The [NAME] revealed: The QAA Committee meets every month on the last Friday of the month.

The committee consists of the Medical Director, Administrator, DON, Assistant Director of Nursing (ADON) and all interdisciplinary team members. The focus of QA committee is to identify problem issues in the facility, track and trend and identify any opportunities for correction in the systems, implement interventions to correct the issue and monitor the effectiveness of the interventions though audits, staff feedback, town hall meetings with staff, education and training and observations on return demonstrations of trainings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 105803