Ponce Plaza Nursing & Rehabilitation Center

F-F645-PASRR Screening for Mental Disease (MD) and Intellectual Disability (ID) was cited as the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASARR) was completed accurately prior to admission and failed to revise the screening following admission for four (4) Residents.

Review of the facility policy and procedure titled Quality Assurance and Performance Improvement revision date 01/01/25 states: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

The QAPI plan will address the following elements:

a. Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions.

b. Policies and procedures for feedback, data collection systems, and monitoring.

c. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following:

Tracking and measuring performance;

Establishing goals and thresholds for performance improvements;

Identifying and prioritizing quality deficiencies;

Systematically analyzing underlying corrective action or performance improvement activities.

Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 106021 Department of Health & Human Services Printed: 08/27/2025 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 106021 B. Wing 05/15/2025

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

Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

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 d. A prioritization of program activities that focus on high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique Level of Harm - Minimal harm or population the facility serves. potential for actual harm e. A commitment to quality assessment and performance improvement by the governing body and/or Residents Affected - Few executive leaders.

f. Process to ensure care and services delivered meet accepted standards of quality.

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 QAA Committee meetings monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), 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.

Interview on 05/15/2025 at 12:07 PM with the 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 make improvements on the quality of care we provide. Identify issues or potential issues and determine what we can do to prevent these issues from occurring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 106021 Department of Health & Human Services Printed: 08/27/2025 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 106021 B. Wing 05/15/2025

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

Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

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 interviews, the facility failed to follow infection prevention and Residents Affected - Few control procedures for Residents ( #13, #106, #129, #234). As evidenced by Residents # #13, # 106, #129, and #234 Incentive Spirometer were observed stored at bedside with no protective covering. There were 139 residents residing in the facility at the time of the survey.

The findings included:

Resident #13

During an observation on 05/12/25 at 06:51 AM Resident #13 was in bed asleep, an Incentive Spirometer was on the bedside table with no protective covering (Photo Evidence)

On 05/13/25 at 08:21 AM Resident # 13 was observed in bed awake, eating breakfast, an Incentive Spirometer was being stored on bedside table with no protective covering.

On 05/14/25 at 11:20 AM Resident # 13 was sitting on side of bed, receiving therapy provided by rehab staff, no distress noted, the Incentive Spirometer not in the room.

Review of the medical records for Resident # 13 revealed the resident was admitted to the facility on [DATE REDACTED]. Clinical diagnoses included but not limited to: Chronic Respiratory Failure with hypoxia.

Resident #106

During observation on 05/12/25 at 06:55 AM Resident #106 was in bed asleep, Incentive Spirometer at bedside stored with no protective covering (photo evidence).

Observation on 05/13/25 at 08:20 AM Resident #106 was in the room, family visiting, Incentive Spirometer being stored at bedside with no protective covering.

On 05/14/25 at 10:01 AM Resident #106 was observed in room in wheelchair, family at side,the Incentive Spirometer was stored at bedside with no protective covering.

Review of the medical records for Resident # 106 revealed the resident was admitted to the facility on [DATE REDACTED]. Clinical diagnoses included but not limited to: Type II Diabetes Mellitus with Hyperglycemia.

Resident #129

During observation on 05/12/25 at 06:58 AM Resident #129 was in bed asleep,there was an Incentive Spirometer on the bedside table with no protective covering (photo evidence).

On 05/13/25 at 08:11 AM Resident #129 was in bed eating breakfast, the Incentive Spirometer stored at the bedside had no protective covering

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 106021 Department of Health & Human Services Printed: 08/27/2025 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 106021 B. Wing 05/15/2025

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

Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

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 05/14/25 at 09:56 AM Resident #129 was in room receiving care from staff, the incentive Spirometer stored at bedside had no protective covering. Level of Harm - Minimal harm or potential for actual harm Review of the medical records for Resident #129 revealed the resident was admitted to the facility on [DATE REDACTED]. Clinical diagnoses included but not limited to: Traumatic Subdural Hemorrhage with loss of Residents Affected - Few consciousness.

Resident #234

During observation on 05/12/25 at 06:57 AM Resident #234 in bed asleep in bed, Incentive Spirometer on bedside stored with no protective covering (photo evidence).

On 05/13/25 at 08:10 AM Resident # 234 in bed eating breakfast, Incentive Spirometer not at bedside.

Review of the medical records for Resident # 234 revealed the resident was admitted to the facility on [DATE REDACTED]. Clinical diagnoses included but not limited to: Rhabdomyolysis

Interview on 05/14/25 at 09:29 Licensed Practical Nurse (Staff A), 4th floor unit revealed, for the residents that have Incentive Spirometers, when they are not being used, they are stored in a clear bag with the date,

the bag is changed weekly, and the Spirometer is cleaned after each use.

On 05/14/25 at 09:43 AM Licensed Practical Nurse (Staff B), reported (via Spanish/English translator) for the residents that have Incentive Spirometers, when they are not being used they are stored in a clear bag, the equipment is cleaned after each use and the bags are changed weekly, the reason for cleaning the Spirometer and storing in the bag is for infection control prevention.

On 05/14/25 at 10:27 AM Assistant Director of Nursing (ADON) revealed the residents with Incentive Spirometer use them for 15 minutes two times a day, after use they are cleaned and placed in a clear plastic bag, the bag is replaced weekly and dated, so the nursing staff know when to replace the bags. This is done daily for infection control purposes, we do the same procedure for oxygen tubing and nebulizer masks.

On 05/15/25 at 08:48 AM Director of Nursing (DON) revealed the three residents observed with Incentive Spirometers in their rooms, no longer have orders for the use of the Incentive Spirometers, those residents choose to keep the Incentive Spirometers, as a result the Incentive Spirometers are now considered personal property of those residents and do not need to be stored in protective covering. In addition.

Review of the facility policy and procedure titled Infection Prevention and Control and Surveillance Program revision date 01/2025 states: 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 106021 Department of Health & Human Services Printed: 08/27/2025 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 106021 B. Wing 05/15/2025

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

Ponce Health and Rehabilitation Center 335 SW 12 Avenue Miami, FL 33130

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 policy and procedure titled Incentive Spirometers dated 01/2025 states all residents who use

an Incentive Spirometer must have a dedicated device. Incentive Spirometers must be cleaned routinely Level of Harm - Minimal harm or according to this policy to prevent respiratory infections and ensure device functionality. Weekly cleaning potential for actual harm instructions by 11-7 nursing staff: #7. Store the device in a clean, dry area within the resident's room.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 106021