Claridge House Nursing & Rehabilitation Center

F-F867 QAPI-QAA Improvement Activities.

Review of the Policy and procedures revealed; It is the policy of the 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 facility will take action aimed at performance improvement as documented in QAA committee meeting minutes and action plan. Performance/success of action will be monitored in subsequent QAA Committee or sub-committee meeting.

Corrective action plans should include, but not limited to, the following:

A definition of the problem

Measurable goals and targets

Step by step interventions to correct the problem and achieve established goals.

A description of how the QAA committee will monitor to ensure changes yield the expected results.

The facility will utilize Root Cause Analysis and the Plan, Do, Study, Act (PDSA) cycle of improvement to improve existing processes. Chosen actions for change will be linked to the root causes and will be designed to effect change at the systems level.

To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA Committee meetings in accordance with QAPI plan, but no less than annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 105513 Department of Health & Human Services Printed: 09/10/2025 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 105513 B. Wing 01/24/2025

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

Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North 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 39177 potential for actual harm Based on observations records reviewed and interviews the facility's staff failed to implement infection Residents Affected - Few prevention control precautions as evidenced by staff failed to follow Enhanced Barrier Precautions during Tracheostomy care for one out of two residents with tracheostomy in the facility.

The findings included:

Observation on 01/22/2025 at 02:09 PM Resident #3 was in bed with eyes closed, gurgling sounds and vomit draining from her the mouth. The tube feeding was infusing at 65 ml/hr.

On 01/22/2025 at 02:30 PM Staff B, RN Supervisor entered the room performed hand hygiene put gloves on, did not put a gown, he checked the resident's mouth removed gloves and exited the room.

On 01/23/24 at 8:03 AM before entering Resident 6's room an Enhanced Barrier Precautions sign was noted posted, and Personal Protective Equipment (PPE) was observed in a plastic container with drawers at the doorway. Resident #6 was observed in bed in distress with loud gurgling sounds noted coughing and drooling; the resident shaking his head from side to side with facial grimacing indicating he is not feeling well, when asked if he is in pain he nodded his head indicating yes. The oxygen was at 4 Liters Per Minute (LPM) via Tracheostomy, tube feeding was infusing at infusing at 75 ml/hr. The nurse was called to the room. Staff

A and RN entered the room to assist the resident, and repositioned the resident. the supervisor was not wearing a mask was noted speaking very close to the resident in a loud tone; The supervisor checked the bowel sounds with his stethoscope exited the room and did not clean his stethoscope both. Both Staff A, and Staff B were not a gown while checking the resident Peg tube.

On 01/23/2025 Staff A, RN acknowledged he did not follow infection prevention and control policy and procedures for Enhanced Barrier Precautions (EBP) while providing care to Resident #6.

On 01/23/25 at 03:52 PM Staff B, RN acknowledged he did not follow and implement infection prevention and control precautions while caring for Resident #3 and Resident #3 at all times.

Review of the facility's Policy and Procedures: for Infection Prevention and Control Program Issued: 6/2020 and Revised:9/29/2021, 6/2023 indicates: 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.

Item 16: All shared medical equipment will be cleaned using an EPA-approved disinfectant wipe effective against TB and Hepatitis B.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 105513 Department of Health & Human Services Printed: 09/10/2025 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 105513 B. Wing 01/24/2025

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

Claridge House Nursing and Rehabilitation Center 13900 NE 3rd Court North 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 The Policy and Procedures: Titled Enhanced Barrier Precautions; Issued: 8/16/2022 and Revised: 4/1/2024 indicate: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Level of Harm - Minimal harm or Precautions will be implemented during high-contact resident care activities when caring for residents that potential for actual harm have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 105513