Terrace Of Hialeah, The

Review of the facility policy and procedure titled Restraints revision date 10/06/24 states: The purpose is to ensure each resident is to attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints.

To ensure residents are provided a safe environment and the use of restraints is carefully monitored to protect resident rights, personal comfort and safety, assuring the least restrictive means are used.

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

last 7 days and Section O for special treatment revealed no therapies coded.

at risk for adverse reactions related to the use psychotropic meds on Anti-Anxiety Medication and on

medications, monitor for signs and symptoms of over-sedation and or changes in condition.

Record review of Psychiatric Note dated 5/23/24 revealed Resident #127 had diagnosis of Schizoaffective disorder, bipolar type and Anxiety.

Record review of physician orders revealed orders dated 6/6/24 for Clonazepam Oral Tablet 1 mg *Controlled Drug* Give one by mouth two times a day related to anxiety disorder.

On 06/25/24 at 11:50 AM the Social Services Director stated: I started working in this facility 4 weeks ago and I am going thru all the PASRRs to make sure they are correct.

There are a lot of outdated PASRRs that I am correcting. I don't have a physical audit form regarding correcting the PASRRs.

The nurses are to inform me during the morning meeting whenever a new qualifying diagnosis is obtained for the resident the I complete a PASRR for that resident on 5/23/24.

Record review of Policies and Procedures for Preadmission Screening and Annual Resident Review (PASARR) Effective date 11/28/2012 last review 10/17/2023.

Guidelines: It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level I) for all new and readmission per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition.

Based upon the Level I screen, the facility will not admit and individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. If a provisional admission to the facility is approved via the Level II screen process, the facility will coordinate with the State PASRR representative related to the individual needs of the resident as indicated.

Annually and with any significant change of status, the facility will complete the PASRR Level I screen for those individuals identified per the Level II screen requiring specialized services.

The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly.

Objective PASRR Policy.

The objective of the PASRR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting.

The PASRR will be evaluated annually and upon any significant change for those individuals identified.

Procedure: 1-Admissions and Readmissions: a) The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD) intellectual disability (ID) or related condition.

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

prevent accidents.

observations, interviews and record review facility failed to provide a safe environment for one

observed in the drawer next to the resident's bed.

There were 231 residents residing in the facility at the time of survey.

The findings included: On 06/23/24 at 11:27 AM Resident#188 was observed laying in bed with eyes closed, a bundle of shaving razors was observed in the drawer next to bed. (photo evidence) On 06/23/24 at 11:27 AM Staff G, Registered Nurse (RN) was notified by surveyor and entered room with surveyor.

Staff G, RN retrieved the bundle of razors and stated; these razors should not be in here for safety reasons because [Resident #188] can reach into drawer. I think a staff member left the razors in drawer.

Record review of demographic sheet for Resident #188 revealed an admission date of 3/27/23 with diagnosis that included Alzheimer's disease with late onset.

Record review of Annual Minimum Data Set (MDS) dated [DATE], Section C for cognitive patterns revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a scale of 0-15 indicated severe cognitive impairment.

Section E for behavior revealed no Potential Indicators of Psychosis.

Section GG for functional status revealed R#188 was dependent for Activities of Daily Living (ADL).

Record review of Care Plan date initiated 3/27/23 and start date 3/31/24 revealed Resident #188 was at risk for falls related to unawareness of safety needs with interventions that included: maintain an environment free of clutter.

On 06/23/24 at 1:28 PM Staff L, Certified Nursing (CNA) (translated by the DON) stated: I have been employed for seven years in this facility; when I start my shift, I check all the residents, tell them what I am going to do and I check all their personal belongings to make sure there are no objects that can be used to harm themselves or others like knife or forks.

Razors cannot be kept in resident's rooms, once used the razors need to be placed in the sharps container.

On 06/26/24 at 10:03 AM, the DON stated: Residents are not allowed to keep razors in their rooms. staff check residents' drawers every day to ensure that there are no objects that harm anyone.

Record review of policy for Hazardous Areas, Devices, and Equipment.

Revised July 2017.

Policy Statement: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

Policy Interpretation and Implementation: 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee.

Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness.

Examples of environmental hazards include, but are no limited to : c.

Sharp objects that are accessible to vulnerable residents.

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

Review of the facility's policy and procedure titled Oxygen Concentrator revision date 05/04/23 states: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.

Policy Explanation and Compliance Guidelines:

• Oxygen is administered under orders of the attending physician, except in case of an emergency.

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

Review of Resident # 201's Significant Change Minimum Data Set (MDS) dated [DATE] revealed:

0-15 scale, indicating resident is cognitively intact.

On 6/23/24 at 9:20 AM Registered Nurse, Staff B stated he is still allowed to give the resident the medication even though it was missed on the initial medication pass.

On 06/25/24 at 08:20 AM, the Director of Nursing (DON) stated: I am aware of the issues identified during medication administration observation, we have already started education with the nurses, the residents' orders were reviewed, and the necessary changes were made.

Review of the facility policy and procedures titled Medication Administration revision date 2/20/24 states: Medications are administered by license nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

105803 06/26/2024

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

Review of the facility policy and procedures titled Medication Administration revision date 2/20/24 states: Medications are administered by license nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

105803 06/26/2024

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

Based on observations, interviews and record review facility failed to properly store medications for

observations of a bottle of vitamins on the side table next to Resident#73 and a nasal spray and rubbing alcohol on Resident #24's side table.

There were 231 residents residing in the facility at the time of survey.

The findings included: On 06/23/24 at 11:21 AM Resident #73 was observed in bed awake and alert. A bottle labeled {supplement} was observed on the resident's side table next to the bed. (photo evidence) On 06/23/24 at 11:22 AM Staff G, Registered Nurse (RN) was notified by surveyor and entered the room with the surveyor.

Staff G, RN removed the bottle labeled [supplement] and explained to the resident that she is not allowed to keep any medications at bedside without first notifying the nurse. Resident #73 replied ok.

On 06/23/24 at 11:22 AM Staff G, RN stated: I do rounds when I start my shift and check each resident. I did not observe this medication at the resident's bedside. I will notify the physician.

On 06/23/24 at 11:17 AM Resident #24 was observed walking into room. A bottle labeled [ Brand} Nasal Decongestant was observed on overbed table and a bottle labeled [Brand} rubbing alcohol on the side table next to the bed (photo evidence).

On 06/23/24 at 11:18 AM Staff H, RN was notified by surveyor and entered the room with the surveyor.

Staff H, RN removed the bottle and explained to Resident #24 that medications are not allowed to be kept at bedside without first notifying the nurse. Resident #24 responded ok.

On 06/23/24 at 11:20 AM Staff H, RN stated: I did not see this medication upon initial rounds, and I will notify the physician.

On 06/26/24 at 10:03 AM The director of Nursing (DON) stated: Residents are not allowed to keep medications in rooms without an order from the doctor and assessed by the nursing.

Record review of Policy: Medication Storage effective date: 10/1/15 Revisions: 2/5/18, 7/2/19, 5/5/22, 10-11-23.

Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles.

Guidelines: 2.

Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding.

105803 06/26/2024

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

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.

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

F-F689 Free of Accidents and Hazards.

The facility was cited for

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.

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