Pines Nursing Home

F-F880- Infection Prevention & Control was cited due to the facility's failure to implement infection control procedures related to staff's not changing gloves during tracheostomy care and staff failure to adhere to proper sharps disposal related to used Blood Glucose Monitoring supplies.

Review of the facility's policy and procedure titled Quality Assurance and Performance Improvement revision dated/02/25 states: These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety.

The facility will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 02/27/2025, 03/27/2025, and 04/24/25 documented the facility had a QAA Committee had meetings monthly.

Interview on 04/30/2025 at 3:00 PM Administrator (NHA) stated the QAA Committee meets every month, the last meeting was held on 04/24/2025. The committee consists of the Medical Director, Administrator, Director of Nursing (DON), Infection Preventionist and all interdisciplinary team members. The purpose of QAPI is to meet with the IDT ( interdisciplinary team) staff to make improvements for the residents, measure results, determine what issues to be worked on and need to be corrected. Make improvements and have interventions in place to have better patient/resident outcomes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 105057 Department of Health & Human Services Printed: 08/28/2025 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 105057 B. Wing 04/30/2025

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

Pines Nursing Home 301 NE 141 Street Miami, FL 33161

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** 45019 potential for actual harm Based on observation, record review and interview, the facility failed to implement infection control Residents Affected - Few procedures for two Residents (Resident 23 and Resident #34), out of 20 sampled residents. As evidenced by staff failed to dispose used Blood Glucose Monitoring supplies in the sharps container, failed to clean the insulin vial before extracting medications via needle syringe and failed to wear Personal protective equipment (PPE) during catheter care for one ( Resident # 34)out of one resident reviewed indwelling urinary catheter. There were 44 residents residing in the facility at the time of the survey.

The findings Included:

During a Blood Glucose Monitoring observation on 04/27/25 at 11:08 AM for Resident #34 with Staff A, Licensed Practical Nurse. Staff A prepared the supplies, entered the resident's room, identified the resident, explained treatment, washed hands, donned gloves, cleaned the residents right index finger with an alcohol pad, checked the Blood Glucose (BG), the results was 326. Staff A, cleaned the resident's right index finger again with an alcohol pad, discarded lancet, blood glucose test strips and used alcohol pads in the garbage can in the resident's room. Staff A exited room, cleaned blood glucose machine with micro kill-wipes, let dry, returned the unused supplies to the medication cart, checked resident's sliding scale orders-Eight (8) units of insulin required. Staff A extracted eight (8) units of insulin from the insulin vial using a needle syringe, Staff A did not clean the top of insulin vial with an alcohol pad before inserting the needle syringe into the vial.

Interview on 04/27/25 at 11:32 AM, Staff A revealed she forgot to wipe the top of insulin vial with an alcohol pad before inserting the syringe needle into the insulin vial to withdraw the 8 units of insulin needed for administration to Resident #34 and was not sure if she was allowed to put any unused supplies taken into a resident's room back in the cart and she placed all the used supplies into her gloves and disposed it in the garbage can in the resident's room; and thought that was ok because the used supplies were wrapped in the gloves.

Interview on 04/30/25 at 08:36 AM, the Director of Nursing (DON) was informed of the concerns mentioned above related to infection control procedures and care for the residents.

Review of the facility policy and procedure titled Infection Control revision date 10/2019 states: The facility will develop and maintain an effective infection control program that protects residents, families, visitors and staff by preventing and controlling infections and communicable diseases as an integral part of the quality assessment performance improvement program. The infection control program will be in accordance with States and Federal Regulations. and national guidelines. The Infection Preventionist will ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection.

51065

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 105057 Department of Health & Human Services Printed: 08/28/2025 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 105057 B. Wing 04/30/2025

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

Pines Nursing Home 301 NE 141 Street Miami, FL 33161

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 On 04/30/2025 at 10:24 AM during Resident #23's indwelling urinary catheter care observation being performed by Licensed Practical Nurse (Staff C) The nurse performed hygiene care gathered catheter Level of Harm - Minimal harm or supplies and entered Resident #23's room identified the resident explained procedure and provided privacy. potential for actual harm Staff C did not put on a gown, Staff C performed hand hygiene, perineal care and catheter care, discarded used supplies in a biohazard bag washed hands exited the resident's room and placed the bag in the Residents Affected - Few biohazard bin (located outside).

Review of medical records for Resident #23 revealed, the resident was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Clinical diagnoses include Paraplegia and Neurogenic Dysfunction of Bladder.

Review of the Physician Orders Sheet for October 2024 revealed, Resident #23 had orders that included but were not limited to: [] indwelling catheter Care every shift. For April 2025, revealed, Resident #23 had orders that included but were not limited to: Enhanced Barrier Precautions (EBP) for risk of infection related to indwelling medical device every shift.

Review of Resident #23's Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed: Resident # 23 is cognitively intact; needs substantial or maximal assistance for toileting hygiene and care and has an indwelling catheter.

Record Review of Resident #23's Care Plan reference date 04/11/2025 revealed: Resident #23 is at risk for urinary tract infections due to indwelling catheter use. Interventions included but not limited to: Change catheter, tubing, and drainage bag as ordered, catheter care daily and as needed, and monitor amount, character, color, odor of urine output, note for recurring urinary tract infections.

Interview on 04/30/2025 at 11:08 AM, Staff C revealed, Resident #23's catheter care is done daily and as needed, and handwashing is the number one priority. Infection control practices we implement for a patient with a [indwelling catheter] is always following Enhanced Barrier Precautions (EBP) by using Personal Protective Equipment (PPE) and handwashing. PPE includes using gloves, gown, mask, and eye protection (if needed). PPE helps prevent infection.

During an interview on 04/20/2025 at 11:30 AM Staff D, Registered Nurse Supervisor revealed: when a patient is on EBP, there would be PPE inside the patient's room and the nurse should always wear PPE when taking care of patients on EBP. Nurses will know if a patient is on EBP when they receive report at the beginning of shift and the nursing supervisor always tries to reinforce it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 105057