Terrace of Hialeah, the

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for five residents (#9, #90, #214, #240, and #258) out of 37 residents on oxygen therapy. As evidenced by oxygen observed being administered at incorrect rates via nasal cannula from concentrators. There were 235 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) program. As evidenced by repeat citations related to F0584 - Housekeeping and Maintenance, F0645 - Pre-admission Screening and Resident Review (PASARR, F0695 - Respiratory Care and F0867- QAPI/Quality Assessment and Assurance (QAA) Improvement Activities). There were 235 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to ensure a sanitary, clean and homelike environment as evidenced by soiled stains on toilet seats in residents' bathroom, trash on floor in residents' bathroom, dirty hallway walls, and ripped bedside chair cushions in a resident's' room. There were 235 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident #9) out of 6 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS for Special Treatments, Procedures, and Programs related to Oxygen therapy for Resident #9. There were 235 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for one (Resident # 16) out of two sampled residents, as evidenced by not including Serious Mental Illness (SMI) diagnosis on the resident's PASARR form. There were 235 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a clean and sanitary environment for residents as evidenced by during several observations, garbage was observed on the floor in several residents' rooms, bed linen was observed on resident's bed with multiple holes, hole in wall in resident's room, and dirty walls in resident's room. There were 231 residents residing in the facility at the time of the survey. The findings Included: During observation on 06/23/24 at 06:18 AM rooms [ROOM NUMBERS] were observed with garbage on the floor. On 06/23/24 at 06:35 AM room [ROOM NUMBER] was observed with garbage on the floor, on 06/23/24 at 06:39 AM room [ROOM NUMBER] was observed with garbage/papers on floor, on 06/24/24 at 07:41 AM room [ROOM NUMBER] bed A was observed with several holes on the bed linen. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one (Resident #435) out of 35 sampled residents was free from the use of physical restraints. As evidenced by during an observation the resident's bed was positioned with the foot of the bed elevated and the head of the bed flat, the overbed table was positioned by the side of the bed in the middle, preventing the resident from getting out of the bed without assistance. There were 231 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I PASRR was not completed for four (Resident # 60, Resident # 3, Resident #112 and Resident #127) out of four residents investigated. This deficiency had the potential to affect 231 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review facility failed to provide a safe environment for one resident (Resident #188) out of ten residents sampled as evidenced by a bundle of shaving razors observed in the drawer next to the resident's bed. There were 231 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for one Resident (#123) out of 35 sampled residents. As evidenced by, during several observations of Resident #123 the Continuous Positive Airway Pressure (CPAP) machine was positioned on Resident #123's forehead.

Inspectors wroteOn 06/24/24 at 3:45 PM a controlled medication count was completed with Staff J, Registered Nurse (RN) in Nursing Unit Center Court on medication cart one, the Narcotic Drug Count Record sign in /out sheet for Unit C. Court Cart one Month/Year June 2024 no signature for 7:00 AM to 3:00 PM off going staff. (see photo evidence). Further review revealed the Medication Monitoring/ Control Record for Resident #145 Clonazepam 0.5 mg one tablet by mouth twice daily noted the last signature was Staff J, Registered Nurse (RN) on 6/23/24 at 4:18 PM, noted number of medications remained as 55. However, on the Bingo card for Resident #145 the Clonazepam 0.5 mg one tablet by mouth twice daily contained 54 tablets and the Medication Administration Record for 6/24/24 for Resident #145 revealed Clonazepam 0.5 mg was given at 9:01 AM by Staff G, RN. (see photo evidence). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five (5) percent or greater. As evidenced by the omission of two (2) medications for residents during medication administration observations with Registered Nurses. There were 231 residents residing at the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review facility failed to properly store medications for two residents (Resident #73, Resident #24) out of ten residents sampled as evidenced by 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.

Inspectors wroteBased on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in problem areas related to repeated deficient practices for F645 PASRR Screening for Mental Diagnosis (MD) and Intellectual Disability (ID), F755 Pharmacy Services and Procedures and F689 Free of Accidents and Hazards. The facility was cited for F645, F689 and F755 in 2023. These repeated deficient practices have the potential to affect any of the 231 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the dishwashing machine was operating properly. This has the potential to affect 218 who ate by mouth out of 237 residents who reside in the facility at the time of survey.

Inspectors wroteBased on observations and interviews, the facility failed to ensure privacy of confidential information by leaving unlocked computer screen with resident's information visible. Observation on 02/05/2023 at 12: 57 PM, the computer for Center Court unit middle cart electronic medical records screen was left open with visible residents' information exposed. On 02/05/2023 at 12: 57 PM, during an interview Registered Nurse (Staff B) was asked about the computer screen that was left unlocked with residents' information exposed. Staff B acknowledged the concern and stated a resident called her and she went to see what the resident needed.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (Resident #237, and Resident #123) out of 38 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section for Discharge Status for Resident #237 and inaccurate coding of the MDS sections for Active Diagnosis and Medications for Resident #123. The facility census was 237 residents at the time of the survey.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for individuals with a Serious Mental Illness (SMI) or Intellectual Disability (ID) or related conditions was completed at the time of admission for resident one (Resident # 54) out of one resident whose PASRR was reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide an ongoing activities program for one out of 38 sampled residents (Resident #112). There were 237 residents residing in the facility during the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure 1 out of 9 sampled residents (Resident #112) reviewed for Accidents and environment remained free of accident hazards. Resident #112 had an electrical socket next to bed that had exposed electrical wires. There were 237 residents admitted to the facility during the survey.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure pharmaceutical procedures were followed during medication administration for two (Resident # 52 and Resident #78) out of seven (7) residents sampled, as evidenced by the correct medication dosage amount not being available on Manor two (2) Carts Number one (1) and three (3) for medication administration to residents, Middle cart on Center Court unit. Loose pill found in Cart One (1) on [NAME] House unit. This had the potential to affect the 237 residents residing in the facility at the time of the survey.