Miami Shores Nursing And Rehab Center

F-F880 Infection Prevention & Control was cited related to the fact that the facility failed to implement infection control procedures for three (Residents 89, 347, 348) out of 28 sampled residents.

Interview with the Director of Nursing (DON) on 03/26/25 at 03:44 PM. She stated that the Quality Assurance and Performance Improvement (QAPI) meetings are held each month. She stated that QAPI committee members are Medical Director, Administrator, Director of Nursing, Social Services, Business Office Manager, Dietary, MDS (Minimum Data Set), and Wound Care. She stated that they have daily meetings, and monthly recap meetings. They started reviewing the last meeting and focusing on the deficiencies the facility had in

the last survey. She stated the way they monitor Quality Assurance is to continuously communicate with the different departments and make sure we track the corrective actions implemented. They also provide in-service education and regular performance review. She said staff addresses any concerns to their supervisor. Residents with weight issue get weighed weekly, if residents are not eating they have a team put

a plan into place. When asked about staffing, she revealed they met the state requirements and they have increased supervision 7:00am-7:00pm.

Record review of Quality Assurance/Quality Assurance Performance Improvement QAPI/QAA Goals/Purpose Statement: Our purpose is to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident/patient outcomes and perceptions of patient care. [ .] has a Performance Improvement Program which systematically monitors, analyses and improves its performance to improve resident/ patient outcomes. It recognizes that the value in healthcare is the appropriate balance between good measures, excellent care and services and cost. We will monitor our operations for compliance with federal and state regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 105449 Department of Health & Human Services Printed: 09/03/2025 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 105449 B. Wing 03/26/2025

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

Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51356 potential for actual harm Based on observation, record review and interviews, the facility failed to follow their infection control protocol Residents Affected - Some in the East side soiled utility room and with Resident's #2 and #57. This is evidenced by trash and food

observations on the floor inside the resident's pantry room on the East side nursing station, Resident #2 indwelling catheter tube touching floor, staff not wearing proper personal protective equipment (PPE) when entering droplet precaution rooms during meal tray distribution and Improper hand hygiene during wound care. There were 96 residents residing at the facility at the time of the survey.

The findings included:

1) On 03/23/25 at 07:51 AM, Staff were observed not wearing PPE while entering a contact/droplet resident room while distributing breakfast trays.

2) On 03/25/25 at 11:02 AM, observation of Wound Care. The Wound Care Nurse gathered supplies that consist of kerlix, normal saline, collagen, tape, 4 x 4 gauze, scissors, red bag and chuck pads. The Wound Care Nurse locked the computer and cart, knocked on the residents' door, provided privacy, washed hands, applied gown and double gloves. The old dressing dated 03/23/25. The Wound Care Nurse removed the old dressing and one pair of gloves. The Wound Care Nurse sanitized the gloves and applied a new pair of gloves. The Wound Care Nurse cleaned the wound, removed one pair of gloves and applied another pair of gloves. The Wound Care Nurse placed collagen power and 4 x 4 gauze on the wound, wrapped the kerlix and dated the tape on the wound. The Wound Care Nurse removed the gloves, gown, washed hands, throwed the red bag in biohazardous bin in the biohazard room, washed hands and signed off on treatment record.

Review of the medical records for Resident #57 revealed the resident was admitted to the facility on [DATE REDACTED]. Clinical diagnoses included but were not limited to: Unspecified open wound, right lower leg, initial encounter.

Review of the Physician's Orders Sheet on 03/24/2025 revealed that Resident #57 had an order for Collagen-Antimicrobial External Sheet (Collagen-Antimicrobial) Apply to Left lateral leg topically every day shift every other day for Surgical Wound Cleanse left lateral leg with normal saline, pat dry, apply Ag collagen sheet cover with 4x4 and wrap with kerlix every other day and as needed until resolved and Apply to Left lateral leg topically as needed for Surgical Wound Cleanse left lateral leg with normal saline, pat dry, apply Ag collagen sheet cover with 4x4 and wrap with kerlix every other day and as needed until resolved.

Review of the Physician's Orders Sheet on 03/11/2025 revealed that Resident #57 had an order to Offload bilateral heels with pillows while in bed as tolerated, every shift.

Review of the Physician's Orders Sheet on 02/20/2025 revealed that Resident #57 had an order for a Geriatric air mattress in place to promote wound healing and as preventative measures. Check for proper functioning every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 105449 Department of Health & Human Services Printed: 09/03/2025 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 105449 B. Wing 03/26/2025

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

Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150

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 0880 Review of the Physician's Orders Sheet on 01/06/2025 revealed that Resident #57 had an order to Turn and reposition every (q) 2 hours (hrs) and as needed, every shift. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #57's Minimum Data Set (MDS) dated [DATE REDACTED] revealed: Section C for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Score of 15, on a 0-15 scale indicating the Residents Affected - Some resident is cognitively intact. Section GG for Functional Abilities documented the resident is dependent on toileting, showering, upper and lower body dressing. Section H for Bowel and Bladder documented Resident #57 is always incontinent. Section J for Health Conditions documented no falls since admission. Section K for Nutrition documented no or unknown loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last 6 months. Section M for Skin Conditions documented diabetic foot ulcers and pressure injury device for bed.

Record review of Resident #57's Care Plans revealed the resident has a diabetic ulcer of the right lateral lower leg and is at risk for complication.

Interventions include- Geriatric air mattress in place to promote wound healing and as preventative measures. Check for proper functioning every shift. Monitor Blood Sugar Levels. Monitor pressure areas for color, sensation, temperature.

Interview on 03/25/25 at 11:23 AM with the Wound Care Nurse it was stated she has been the wound care nurse at this facility since 2022. The measurements for the wound on 3/13/25 were 6.2x4.7x0.2 cm and it is improving but the resident is non-compliant and refuses treatment or medications. The Resident has diabetes that slow down wound healing process. She has supplements like multivitamin for hair, skin and nails. The Resident is on enhanced barrier precautions for the open wound. The Resident has pain management and receives Percocet and Tylenol around the clock. The Resident has orders for an air mattress for offloading, pillow offloading, turn and reposition every 2 hours, bunny boots and weekly skin checks by nurses. The protocol for the new resident would be doing a skin integrity assessment form. She would fill out the form with the residents' information, do a head-to-toe assessment, document and if they have a wound, she would asses the wounds and call whichever doctor is responsible. I would ask the doctor what to order for the patient, insert the orders and make a note. There is a log for residents with wounds on admission and initial treatment. The Wound Care Nurse states she would put an order for an air mattress if required and call the family to explain what was found. The podiatrist comes every Thursday. The podiatrist sees patients with wounds from the knee down and the wound doctor see patients hip and up. The wound doctor comes on Tuesday's. The Wound Care Nurse states she rounds with the doctors. The surveyor asked

the Wound Care Nurse why she used doubled gloves during the care and she stated it is within the protocol and she has doubled gloved during wound care observations in the past with the Agency for Healthcare Administration (AHCA) and they have been okay with it.

3) Interview on 03/26/25 at 12:54 PM with Staff H, Registered Nurse (RN) stated before entering the room, I fully apply PPE before going inside. Gown, gloves and mask. I received education about infection control and handwashing by Staff T, RN. The staff test for covid almost every day and a staff nurse does it. The residents stay isolated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 105449 Department of Health & Human Services Printed: 09/03/2025 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 105449 B. Wing 03/26/2025

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

Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150

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 0880 Interview on 03/26/25 at 12:30 PM with Staff I, Licensed Practical Nurse (LPN) stated, I have been a nurse at

the facility for [AGE] years. Before entering a residents room, the staff should put on PPE which consist of Level of Harm - Minimal harm or gloves, gown and mask. As a nurse, I would only test residents if they have signs or symptoms of covid. potential for actual harm After the resident is positive, they should have 3 negative tests to be taken off isolation. I have received education about handwashing and infection control by a supervisor or Staff T, RN. Residents Affected - Some

Interview on 03/26/25 at 02:20 PM with Staff J, LPN it was stated before entering a residents room that is covid positive, I would put on my PPE. I received education on handwashing and infection control almost everyday by Staff T, RN. The supervisors test the residents to see if they are still are positive and they stay

in isolation.

Interview on 03/26/25 at 01:58 PM with DON it was stated I have been the DON at the facility for 2 months. Staff should perform hand hygiene when they encounter residents rooms, handling soiled linen or handling and passing out trays. Staff receive education monthly, have surveillance and on spot teaching by Staff T, RN. Staff should not double glove when giving care to residents. Staff should throw away gloves and wash hands.

Interview on 03/26/25 at 01:09 PM with Staff E, Certified Nursing Assistant (CNA) stated I have been a CNA at the facility for one year. If a resident is covid positive I would put on mask, gown and gloves before entering the room. I have received education on infection control and hand washing, last year by Staff T, RN. I would wash my hands before feeding resident's, giving care, after taking out garbage, laundry and before passing food trays.

Interview on 03/26/25 at 01:15 PM with Staff F, CNA stated I have been a CNA at the facility for [AGE] years. If a resident is covid positive I would wear a gown, glove, hat and mask before entering the room. I have received education on infection control and hand washing, yesterday by Staff T, RN.

Interview on 03/26/25 at 01:24 PM with Staff G, CNA stated she has been a CNA at facility for [AGE] years. If the resident was covid positive, I would clean my hands, knock, apply gown, gloves, mask and shield for droplet precautions. My last education on infection control and handwashing was given a month ago by Staff T, RN.

Review of the facility policy and procedure August 2014 regarding hand washing/hand hygiene states all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used: Before aseptic procedures; When anticipating contact with blood or body fluids; When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions.

48906

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 105449 Department of Health & Human Services Printed: 09/03/2025 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 105449 B. Wing 03/26/2025

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

Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150

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 0880 4) On 3/23/25 at 7:01 AM an observation was made of trash and food on the floor inside the East side nursing station resident's pantry room (see photo). The Surveyor notified Staff L, Licensed Practical Nurse Level of Harm - Minimal harm or (LPN) and Staff L stated, The Resident's pantry room is used to store residents' food and residents who are potential for actual harm capable are allowed to get ice and use the microwave. The surveyor asked why there was trash and food on floor and Staff L, LPN replied, I don't know, I cleaned it when I came on shift. Housekeeping cleans the room Residents Affected - Some in the morning.

On 3/23/25 at 8:43 AM the Environmental Services Director was interviewed about how and when the pantries are cleaned and stated, I clean the residents' pantry Monday thru Friday. Another Housekeeping staff cleans the resident pantry on weekends at 5:00am. There are two resident pantries. That staff member called to let me know she would be late and at that time it was the Porter's responsibility to clean the Pantry.

On 3/23/25 at 8:54 AM Staff Q, Housekeeping staff stated, I normally come in at 5:30 am and clean the pantry. Today I came in at 8:00am and I cleaned it at 8:00am.

On 3/23/25 at 9:08 AM Staff R, Environmental Services (porter) was interviewed and stated, I started work at 5:30am. When I come in I take out the trash Soiled Utility room and then checked the pantry and all the shower rooms. I did not clean the Resident pantry yet when you saw it because I was still taking out the trash from around the building.

5) On 3/23/25 at 7:10 AM The East side Soiled utility room was toured with Staff L, LPN. Staff L, LPN observed entering the room by inputting a code on a keypad. No concerns were observed inside the Soiled Utility room.

When the surveyor walked away, Staff L, LPN was overheard telling another staff member that the door doesn't lock.

At that time, the Surveyor returned to Soiled Utility room with Staff R, Environmental Services (porter) and Staff L, LPN and both staff revealed the Soiled Utility Room door was not able to locked.

On 3/23/25 at 7:58 AM the Maintenance Director revealed the lock was fixed and noted in the maintenance logbook.

6) On 3/23/25 at 7:56 AM a mask and supplement carton was observed in the East Side shower room photo obtained).

7) On 3/23/25 at 10:20 AM There was an observation of two room doors with Droplet Precaution signs posted ajar. The signs included instructions that the door is to be closed at all times (photo obtained). The surveyor observed Staff O, Certified Nursing Assistant (CNA) in the hallway. The surveyor asked if it is within their protocol to leave doors open when residents are under Droplet precautions and Staff O, CNA replied, Sometimes the residents ask to leave the door open. I do not know why the doors were left open, but I will close them. Staff O, CNA closed both doors.

8) On 03/24/25 at 7:38 AM Resident#2 was observed in bed with oxygen in progress at 2 Liters per minute via a nasal cannula, no apparent distress was noted. The urinary catheter tubing was observed touching the floor (photo obtained).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 105449 Department of Health & Human Services Printed: 09/03/2025 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 105449 B. Wing 03/26/2025

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

Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150

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 0880 03/24/25 07:42 AM Staff N, Licensed Practical Nurse (LPN) stated, I did a double and when I rounded this morning, and I checked on Resident#2. At that time the indwelling catheter tubing was not touching the floor. Level of Harm - Minimal harm or It appears the reason it was touching the floor was because someone lowered the bed too low. I round every potential for actual harm two hours and as needed to make sure the proper interventions are in place. I communicate with the Certified Nursing Assistant (CNA) about required interventions for catheter care and I will reinforce. Residents Affected - Some 03/24/25 at 7:53 AM Staff P, CNA stated, I am the CNA taking care of Resident#2 today. I have received in-services catheter care and the nurse speaks to me about catheter care. I empty the collection bag and

record the amount. I don't allow the collection bag to touch the floor. I also make sure it is anchored to the bed. I made rounds this morning and the tubing was not touching the ground and I did not lower the bed. The bed should not be too low because the tubing or bag might touch the ground for infection control purposes.

On 03/24/25 at 8:10 AM the Nursing educator advised the surveyor that the Indwelling urinary catheter system was changed.

On 3/23/25 at 10:24 AM the Director of Nursing (DON) was interviewed about infection control concerns and stated, I have given several in-services about Enhanced Barrier Precaution (EBP) multiple times. The sign says when to use the Personal Protective Equipment (PPE).

On 3/26/25 at 11:44 AM the DON revealed the nursing educator does frequent rounds on the floors and observes staff performing hygiene care and does on the spot teachings. We have 14 residents under Droplet Precautions for either Covid or exposure to Covid. Staff are required to don a gown, mask, gloves, a face shield is optional. The residents on Droplet Precaution doors should be closed. Some residents don't like having the door closed and request to leave it open. It is not recommended to leave the door open but we try to honor residents' rights and if that can't be done we find alternative means and it is care planned. We in-serviced all staff about Covid outbreak, hand hygiene, donning PPE, early signs and symptoms of Covid

on 3/14/25. Staff are to monitor residents' catheters to make sure the urine is draining properly and catheter tubing is not kinked, or touching the floor. The Soiled Utility room door should be kept locked to prevent any infection.

Record review of a POLICY/PROCEDURE: SUBJECT: Infection Prevention and Control and Surveillance Program DATE: January, 2020 INTENT: It is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent

the development and transmission of disease and infection, in accordance with State and Federal Regulations, and national guidelines. PROCEDURE: 1. The facility will establish and maintain an infection prevention and control program under which it: a. Prevents, identifies, reports investigate, and controls the spread of infections and communicable disease in the facility;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 105449 Department of Health & Human Services Printed: 09/03/2025 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 105449 B. Wing 03/26/2025

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

Miami Shores Nursing and Rehab Center 9380 NW 7th Avenue Miami, FL 33150

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 0880 An additional record review revealed a Policy titled SUBJECT: Standard and Transmission-based Precautions. DATE: (no date) INTENT: It is the policy of the facility to ensure that appropriate infection Level of Harm - Minimal harm or prevention and control measures are taken to prevent the spread of communicable disease and infections in potential for actual harm accordance with State and Federal Regulations, and national guidelines. PROCEDURE: Transmission-based Precautions 1. Transmission-based precautions include airborne, contact, and droplet Residents Affected - Some precautions. Residents requiring airborne precautions will be transferred to a hospital or other health care facility with airborne precaution capability.

Residents that require contact and or droplet precautions may remain at this facility. a. Staff are to put on a mask upon room entry and removed upon room exit of resident placed on droplet precautions. 12. a. Staff are to put on gowns and gloves upon room entry and remove gowns and gloves upon exit of resident room.

Further record review revealed a policy titled Enhanced Barrier precautions revealed date written: March 2024 POLICY: Enhanced Barrier Precautions (EBP) will be in place for residents as set forth by CMS guidance pertaining to Multidrug-Resistant Organisms (MDRO's) in Memorandum Ref: QSO-24-08-NH March 20, 2024. Residents will be evaluated on admission for the need for EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 105449