F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain the privacy for one resident
(Resident # 59) out of one resident for privacy as evidenced by, posting a visible sign on the wall of
Resident # 59 room disclosing Protective Health Information (PHI). There were ninety- nine residents
residing in the facility at the time of this survey.
Residents Affected - Few
The findings included:
Observation completed on 11/28/2022 at 10:26 AM revealed Resident #59 resting in bed. Resident #59
was alert but has some confusion. Observation revealed a paper attached to the wall at the head of the
resident's bed with the resident's name and a sign indicating Heart Monitor in Use sign that stated, Please
do not unplug unit. Unplug the power cord will prevent the patient's heart from being monitored. Thank you,
[ name of diagnostic company]. (photographic evidence obtained). When the charge nurse was asked about
the sign, Staff B, Charge Nurse reported that resident has a pacemaker underneath the skin on the left
upper chest and there is a memory device plugged to the wall to record and monitor the heart. Charge
nurse reported resident use the pacemaker for two years with the purpose of long-term use.
On 11/29/22 at 08:38 AM, observed Resident #59 sleeping in bed. Head of bed was elevated. The heart
monitor device was plugged inside the wall. The sign related to the heart monitor in use was not on the wall.
On 11/30/22 at 02:48 PM, Resident #59 was observed sitting in chair, watching television. The sign related
to the heart monitor in use was no longer posted on the wall.
Record review of Resident #59 face sheet revealed initial date of admission [DATE]. Diagnoses included but
not limited to: Hypertensive heart disease, Myocardial Infarction, Dementia, Coronary Artery Disease,
Pacemaker Placement and Cardiomegaly.
Record review of Minimum Date Set (MDS) Quarterly assessment dated on 09/04/2022 revealed: Section
C- for cognitive pattern documented a Brief Interview of Mental Status (BIMS) score of 3 out 15 indicating
Resident #59 is severely cognitive impaired. Section G- for Functional Status indicated total dependence
with extensive assistance for Activities of Daily Living (ADL).
Review of Resident #59's care plan dated on 05/05/22 revealed: Resident cardiac stability will maintain as
evidenced by no shortness of breath, cyanosis, edema, chest pain, stable.
Interview with the DON (Director of Nursing) on 12/01/2022 at 3:50 PM revealed that she did not see
(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 2
Event ID:
105511
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
105511
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hialeah Shores Nursing and Rehab Center
8785 NW 32nd Avenue
Miami, FL 33147
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 0583
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the sign that was posted on Resident #59' wall at the head of the bed. When this surveyor showed the
picture taken during the initial observation of the visible sign indicating: Heart Monitor in Use with Resident
#59 name, heart monitor, and diagnostic testing center telephone number to the DON. The DON stated that
she was not aware and acknowledged that the sign should not have been posted and that the sign was
removed. During the interview the DON added that they are providing education to the staff about resident's
privacy. When a resident is admitted with a medical device such as a pacemaker, she ensured that she has
provided teaching to full time regular staff for each unit. Therefore, the regular full-time staff would be
knowledgeable about their residents' pertinent diagnoses, conditions, and comorbidities.
On 12/01/2022 at 4:30 PM, both the ADON (Assistant Director of Nursing) and (Director of Nursing)
acknowledged that the sign was disclosing PHI (protective health information). They did not know who
posted the sign on the wall. They believed that it was important to protect resident health information and to
promote safety to all the residents.
Rewiew of the facility's Policy and Procedures on Privacy dated 2016 revealed:
Policy: It is the policy of the facility to ensure that resident's privacy is respected.
The Procedures of the Policy about privacy are included but not limited to:
1.
The resident has a right to be treated with respect
2.
Keep residents personal identifying information covered and out of sight.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105511
If continuation sheet
Page 2 of 2
