Inspection·February 29, 2024

F 0641 Ensure each resident receives an accurate assessment. 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 interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident #28) out of one resident reviewed for dental assessments. Resident #28 was coded incorrectly as being edentulous. Residents Affected - Few The findings included: Observation and interview with Resident #28 was conducted via a Spanish translator on 2/27/2024 at 7:45 AM. The resident was sitting up in bed, preparing for breakfast, using a hearing amplifier device to hear. The resident had natural teeth, missing teeth on the bottom and had bilateral hand contractures. She revealed, she had not seen a dentist in a long time and wanted to see the dentist. Review of the Demographic Face Sheet for Resident #28 documented the resident was admitted on [DATE] with a diagnosis of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, schizophrenia, hearing loss and major depressive disorder. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #28 dated 12/22/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 11 out of 15 indicating mild cognitive impairment and the resident was able to make her needs known. The resident required partial/moderate assistance for eating and dependent assistance for ADLs (Activities of Daily Living), no natural teeth or tooth fragments edentulous and was coded Yes. Review of the Dental Care Plan for Resident #28 documented the following: Focus: Resident with some natural teeth loss. Resident has lower natural teeth (some missing pieces) (written 6/19/2023; reviewed and updated); Goals: Resident will not have any s/s (signs/symptoms) of discomfort/complications related to teeth loss left unmanaged through next review date; Resident will not have any s/s of discomfort/complications related to teeth loss or use of dentures left unmanaged through next review date and Interventions: Dental consult as needed/as per facility protocol; Assist resident with oral care daily as needed; Assess for loose fitting dentures and report as needed. On 2/29/2024 at 8:55 AM, interview with the Social Services Director. She stated, She has some natural teeth. On 2/29/24 at 9:46 AM, interview and record review with Staff A, Registered Nurse (RN) MDS (Minimum Data Set) Coordinator on 2/29/2024 at 9:46 AM. She stated, We had a part time MDS Coordinator who conducted the assessment and the assessment is incorrect. It is a coding error. The resident does have teeth. She is not edentulous. The care plan reflects that she has teeth. We are going to do a modification of the MDS. (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 3 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 02/29/2024 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)