Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observations, interviews, and record reviews, the facility failed to properly store controlled
substances on three out of four sampled medication carts as evidenced by unreconciled medication
monitoring/control record sheets. The facility had four medication carts.
The findings included:
On 6/24/2025 at 1:32 PM a medication administration observation was completed with Staff A, Registered
Nurse (RN) on the west wing medication cart #1; Staff A, RN verified the physician's order, removed the
controlled substance from a bingo card placed it in a medication cup; after administering the controlled
substance, Staff A, RN returned to the medication cart and signed in the medication monitoring/ control
record sheet to indicate the controlled substance was given.
Interview on 6/24/2025 at 1:37 PM, the surveyor asked Staff A, RN about the protocol for documenting
removal of a controlled substance. Staff A, RN replied, I sign the narcotic log after the resident takes the
medication because if the resident refuses, I can't sign that I have given it. The surveyor asked Staff A, RN,
to explain the purpose of the narcotic log and what is indicated when a substance is given or removed from
bingo card and if the log needs to be accurate at all times. Staff A, RN revealed, the narcotic log indicates
the substance was removed and yes the narcotic log need to be accurate at all times.
On 6/24/2025 at 1:51 PM a medication storage check was completed with Staff B, Licensed Practical Nurse
(LPN) on the east medication cart #1. At that time the controlled substance log was observed signed and
dated with no time. Upon further review, the electronic administration record (EMAR) was observed
unsigned for the controlled substance. (photo evidence)
Interview on 6/24/2025 at 1:55 PM, Staff B, Licensed Practical Nurse (LPN) revealed the protocol for
signing the narcotic log, Staff B, LPN stated: I administered the medication at 1:19 PM and forgot to sign. I
am supposed to sign at the time I remove the medication from the bingo card.
On 6/24/2025 at 1:58 PM, a medication storage check was completed on the east side medication cart #2
with Staff C, LPN, the Medication Monitoring / Control Record was observed signed, no date written, time
written but the EMAR was observed signed at 8:40 AM. At 2:00 PM a second Medication Monitoring /
Control Record was observed signed, no date written, no time written, amount written, amount written,
amount written, amount correct, and the EMAR was signed for that medication at 9:40 AM. (photo
evidence)
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
105449
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105449
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 6/24/2025 at 2:01 PM, during the continued medication storage check with Staff C, LPN a Bingo card of
controlled substances was observed with a broken seal and tape reinforcing it. (photo evidence)
Interview on 6/24/2025 at 2:01 PM, Staff C, LPN revealed: I didn't have my pen so I couldn't sign the sheet.
Sometimes when the pharmacy sends the medication and the bingo card needs to be reinforced so the pill
doesn't fall out. Someone placed a tape to help. The correct procedure is to call the pharmacy to resend the
medication.
On 6/24/2025 at 3:30 PM, the Director of Nursing stated: Nurses are to verify the physicians' order, verify in
the narcotic book, pop out the narcotic, sign his or her name with time date amount at the time it is taken
out of the bingo card. The narcotic should always be reconciled and signed out. If there is any tear or
abnormality in the bingo card it should be sent back to pharmacy.
Record review of a Policy titled 4.0 Schedule II Controlled Substance Medication (undated) revealed
POLICY: This policy is to ensure adherence to state and federal laws relating to the dispensing of Schedule
II controlled substance medications. In a non-emergency situation, Schedule Il controlled medications will
NOT be dispensed without a written. or electronic prescription. In an emergency and when allowed by
federal and state regulations and in compliance with the required documented follow-up procedure,
Specialty RX, Inc. pharmacies WILL dispense Schedule Il controlled medications upon an oral authorization
but to a 72-hour supply. To dispense Schedule III-V controlled medications, an oral, written, or electronic
prescription is required. A pharmacist may not dispense more than a 30-day supply of a controlled
substance listed in Schedule Ill upon an oral prescription issued in this state.
H. Dispensing of Controlled Dangerous Substance 5. When a CDS medication is administered, in addition
to following proper procedure for the charting of medications, the nurse must document on the declining
inventory sheet the date of administration, the quantity administered, the amount of medication remaining
and his/her initials
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105449
If continuation sheet
Page 2 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105449
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
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 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
Based on observations, record review and interviews the facility's Quality Assessment and Assurance
(QAA)/QAPI) committee failed at demonstrating an effective plan of action to correct identified quality
deficiency in problem areas as evidence by repeated deficient practice for F 880-Infection Prevention and
Control and F 761- Label/Store Drugs and Biologicals. There were 91 residents residing in the facility at the
time of the survey.
The findings included:
Record review of the facility's survey history revealed, during a recertification conducted on March 23, 2025
through March 26, 2025, F880- Infection Prevention & Control was cited due to the facility's failure to
implement infection control procedures related to trash and food observations on the floor inside The
Resident's pantry room on the East side nursing station, indwelling catheter tube touching floor, staff not
wearing proper personal protective equipment (PPE) and improper hand hygiene during wound care. F761Label/Store Drugs and Biologicals was cited related to an unattended unlocked medication cart on the west
side nursing station and medication and glucometer and lancets left at a resident's bedside.
Review of the facility's policy and procedure titled Quality Assurance & Performance Improvement (QAPI)
Plan QAPI 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.
Our nursing home has a Performance Improvement Program which systematically monitors, analyzes 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. Scope - Our
center's full range of services included in our QAPI program are post-acute care and long-term care. The
QAPI committee will consist of representation from Minimum Data Set (MDS), nursing, social services,
dietary, housekeeping & laundry, maintenance, medical records, activities and Risk Management/Staff
education. Therapy, music therapy, human resources, resource development, business office and therapy
departments will be asked for input or sit on a performance improvement project sub- committee as
requested.
Interview on 06/24/2025 at 3:20 PM the Administrator revealed, the QAPI (Quality Assurance and
Performance Improvement) team consists of the Director of Nursing (DON), department heads, the
administrator, wound care nurse, dietary staff, and the medical director. Meetings are held monthly, with the
next meeting scheduled for this Thursday. The purpose of the QAPI meetings is to review quality assurance
initiatives and performance improvement efforts, particularly focusing on previous citations and audit
outcomes. The team evaluates post-survey findings and identifies deficiencies. Supervisors create audit
forms to help track and monitor compliance. Current areas of focus include addressing previous
deficiencies, improving infection control practices, ensuring privacy, preventing unattended medications,
and enhancing documentation practices.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105449
If continuation sheet
Page 3 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105449
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
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 potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation record review and interviews, the facility failed to meet infection control standards of practice
for Resident #5 during hygiene care. This is evidenced by Staff A not performing hand hygiene, changing
gloves or changing washcloths during hygiene care for Resident #5. There were 91 residents residing at the
facility at the time of the survey.
Residents Affected - Some
The findings included:
On 06/24/25 at 01:13 PM, Staff A was observed not performing hand hygiene prior to the procedure. Upon
the surveyor's entry into the room, the Certified Nursing Assistant (CNA) was already wearing a gown,
mask, and gloves. The resident is on enhanced barrier precautions and has a Percutaneous Endoscopic
Gastrostomy (PEG) tube; the PEG tube machine was noted to be turned off. The CNA removed the
resident's soiled clothing, leaving the resident uncovered while filling the basin with water. Soap was added
directly to the water. The CNA did not remove gloves or perform hand hygiene at any point during the
procedure. The resident's face was washed using soapy water, and the same washcloth was used to
cleanse the remainder of the body. After drying the resident, the CNA turned her to wash and dry her back,
then applied a clean brief and gown. Following the procedure, the CNA emptied the basin, removed the
gown, gloves, and mask, and discarded them in the trash.
Review of the medical records for Resident #5 revealed the resident was admitted to the facility on [DATE].
Clinical diagnoses included but not limited to: Dysphagia, unspecified.
Review of the Physician's Orders Sheet on 04/04/2024 revealed that Resident #5 had an order for
Enhanced Barrier Precautions for peg tube use, every shift.
Record review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive
Patterns documented a Brief Interview for Mental Status (BIMS) Score of 00, on a 0-15 scale indicating the
resident is cognitively impaired. Section GG for Functional Abilities documented the resident is dependent
on eating, toileting, showering, sit to lying, upper and lower body dressing. 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.
Record review of Resident #5's Care Plans revealed the resident requires enhanced barrier precaution
related to tube feeding.
Interventions include- Educate resident, responsible party or caregivers regarding enhanced barrier
precaution. Follow infection control guidelines as indicated. Maintain enhanced barrier precaution as
indicated during dressing, bathing/showering, transferring. providing hygiene, changing linens, changing
briefs or assisting with toileting, device care or IV access line care, urinary catheter care, feeding tube care,
tracheostomy/ventilator care, ostomy care, or during wound care.
Record review of Resident #5's Care Plans revealed the resident has an activities of daily living (ADL)
self-care performance deficit related to (r/t) diagnosis (Dx) diabetes mellitus (DM) , osteoarthritis,
hyperlipidemia, dementia and gastroesophageal reflux disease (GERD).
Interventions include - Apply left hand roll when out of bed for support and comfort. Apply Wedge Foam
Cushion to high back WC, for positioning and comfort as tolerated. Enhanced Barrier Precautions
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105449
If continuation sheet
Page 4 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105449
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
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
for peg tube use.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 06/24/25 at 03:30 PM with Director of Nursing (DON) stated Enhanced Barrier Precautions
apply to residents with certain medical conditions, including those with PEG tubes, foley catheters, dialysis
access, wounds, or surgical sites with staples. These residents require a physician's order for enhanced
precautions, which must be acknowledged and signed off on every shift. Clear signage is posted outside
the resident's room to guide staff on when and how to properly don and doff personal protective equipment
(PPE). Non-compliance with these protocols has led to employee terminations in the past, reflecting the
facility's commitment to strict adherence. Education on enhanced barrier precautions is provided weekly by
the staff educator, with additional one-on-one training conducted as needed during real-time observations.
During bed baths, gloves should be changed after cleaning and drying the resident to prevent
cross-contamination. A separate washcloth should be used for the resident's face and replaced immediately
if it becomes soiled.
Residents Affected - Some
Interview on 06/24/25 at 11:43 AM with Staff F, LPN stated a patient is on enhanced barrier precaution if
they have a peg tube, foley catheter or wound. Before entering the patient room, I must make sure I wear a
gown, gloves and mask before providing care. I receive education monthly or when there is a new hiring, by
the infection preventionist.
Interview on 06/24/25 at 12:00 PM with Staff G, LPN stated a patient is on enhanced barrier precaution if
they have a peg tube, wound or any open area. Before entering the patient room, I must wash my hands,
put on my gown, gloves and mask before providing care. I receive education every day, by the infection
preventionist.
Interview on 06/24/25 at 04:00 PM with Staff H, CNA stated the residents on Enhanced Barrier Precautions
usually have wounds, bedsores, Foley catheters, or PEG tubes. Before I give care, I knock on the door,
introduce myself, and make sure I identify the resident. If there's a sign on the door, I get my supplies and
put on a yellow gown, gloves, and a mask. I get training on how to properly wear PPE every other week
from the staff educator. When I give a bed bath, I change my gloves during the process, use a different
washcloth for the face and armpits, and make sure to cover the resident's top half while I wash the lower
body.
Review of the facility policy and procedure January 2018 regarding Bed Bath of Resident states During the
Bed Bath: Cover patient with bath blanket and remove top bed linen (keep patient covered at all times).
Remove gown while maintaining dignity. Begin bath in the following order, using a clean part of the
washcloth for each
1.
Eyes - Wipe from inner to outer canthus, no soap.
2.
Face, neck, and ears
3.
Arms and hands - Support joints; include fingernails.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105449
If continuation sheet
Page 5 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105449
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
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.
Level of Harm - Minimal harm
or potential for actual harm
Chest and abdomen - Keep female patients covered as much as possible.
5.
Residents Affected - Some
Legs and feet - Clean toes and heels well.
6.
Back and buttocks
7.
Perineal area - Use clean gloves; cleanse front to back.
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105449
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
FAQ · About this visit
Common questions about this visit
What happened during the June 24, 2025 survey of MIAMI SHORES NURSING AND REHAB CENTER?
This was a inspection survey of MIAMI SHORES NURSING AND REHAB CENTER on June 24, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MIAMI SHORES NURSING AND REHAB CENTER on June 24, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.