Beachside Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for one of one final sampled residents (Resident 5) reviewed for indwelling urinary catheter (flexible tube inserted into the bladder to continuously drain urine into an external collection bag). * The facility failed to monitor Resident 5's urinary output per the resident's plan of care. This failure had the potential for the resident to develop indwelling urinary catheter related complications. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 4/2025 showed the facility IDT will develop and implement a comprehensive person-centered and culturally competent care plan for each resident and will include each resident's needs identified in the comprehensive assessment. Medical record review for Resident 5 was initiated on 2/22/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility P&P review, the facility failed to provide the necessary care and services related to weight loss for one of four residents (Resident 17) reviewed for nutrition. * The facility failed to ensure the physician was notified when Resident 17 had a weight loss. In addition, the facility failed to conduct an IDT meeting and carried out an RD recommendation related to Resident 17's weight loss. These failures had the potential for the resident to not receive the necessary care and nutritional interventions and could contribute to resident's further weight loss.Findings: Review of the facility's P&P titled Food and Nutrition Services - Nutrition Care Management dated 2/9/26 showed the facility shall ensure all residents maintain acceptable parameters of nutritional status such as usual body weight (UBW) or desirable body weight (DBW) and electrolyte balance, unless the resident's clinical condition or resident preference demonstrates that it is not possible. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for one of one final sampled resident (Resident 86) and two non-sampled residents (Residents 16 and 51) reviewed for the respiratory care. * The facility failed to ensure Resident 86 had a physician's order for the use of oxygen therapy. Furthermore, when Resident 86 had an order for oxygen, Resident 86 was provided with oxygen greater than what was ordered by the physician. In addition, Resident 86's nebulizer mask and tubing were not labeled and stored properly when not in use. * The facility failed to ensure the nebulizer mask and tubing at Resident 16's bedside was labeled and stored in a bag. In addition, the facility failed to ensure the nebulizer mask and tubing at Resident 16's nightstand belonged to the resident. * The facility failed to ensure Resident 51's nebulizer mask was stored in a set-up bag when not in use. These failures had the potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one final sampled resident (Resident 7) and one nonsampled resident (Resident 74). * LVN 7 failed to administer Resident 74's probiotic (supplement) as ordered by the physician. * The facility failed to obtain and document Resident 7's blood pressure and heart rate per the physician's ordered parameters for two medications: amlodipine-olmesartan (blood pressure medication) and metoprolol succinate (blood pressure medication). These failures had the potential to negatively affect the residents' well-being.Findings: 1. Review of the facility's P&P titled Medication Administration (undated) showed medications will be administered as prescribed by the physician, and only by persons lawfully authorized to do so. Medications are administered in accordance with the written orders of the attending physicians. On 2/24/26 at 0836 hours, a medication administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure for proper storage, labeling, and disposal of the medications for two final sampled residents (Residents 2 and 33), one nonsampled resident (Resident 19) and one of three medication carts (Medication Cart A) observed. * The facility failed to ensure Resident 2's hydrocodone-acetaminophen (a controlled drug used to manage severe pain) and Resident 19's oxycodone (a controlled drug used to manage severe pain) medication bubble packs were properly stored in Medication Cart A. * The facility failed to ensure the accurate labeling of one insulin pen stored in Medication Cart A. * The facility failed to ensure the calmospetine (a moisture barrier designed to protect and heal skin irritations, diaper rash, incontinence, and minor wounds) cream was not left unattended by the licensed nurse on Resident 33's bedside table. These failures had the potential to negatively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. The facility failed to ensure Resident 24's wound vacuum machine and the connector tubing were not stored and touching the floor. This failure posed the risk for the resident to develop a wound infection that could negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 10/2022 showed the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/ oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, immunization document review, and facility P&P review, the facility failed to ensure the necessary services related to COVID-19 vaccination was provided for two of five residents (Residents 5 and 7) reviewed for immunizations. * The facility failed to ensure Residents 5 and 7 were provided the education specific to eligibility to receive COVID-19 vaccine. This failure posed the risk for the residents to acquire COVID-19 infection and could negatively affect the residents' health and well-being.Findings: Review of the facility's P&P titled Resident Immunizations revised 4/2025 showed it is the policy of the facility to offer and administer COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine and obtaining consent. To minimize the risk of residents acquiring, transmitting, or experiencing complications from COVID-19, each resident is informed about the benefits and risks of immunizations; and has the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the food items were properly stored and maintained. * The facility failed to ensure the food items were dated and labeled. * The facility failed to ensure the kitchen equipment was maintained in a sanitary condition and/or cleaned properly. These failures had the potential to result in foodborne illnesses for 57 of 59 residents receiving the dietary services in the facility's kitchen. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the facility's kitchen. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to two of 15 final sampled residents (Residents 24 and 31). - The physician's order for the resident to be up in the chair during meals was not carried out for Resident 24. - The physician's order was not obtained and the care plan was not developed for the use of the wander guard for Resident 31. These failures had the potential for these residents to not receive the necessary care and services to meet their care needs. Findings: 1. Review of the facility's P&P titled Physician Orders revised on 11/2019 showed the physician's orders shall be obtained prior to the initiation of any medication or treatment. All the orders must be specific and complete with all the necessary details to carry out the prescribed order without any questions. Medical record review for Resident 24 was initiated on 3/25/25. Resident 24 was admitted to the facility on [DATE], and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for three of three final sampled resident (Residents 4, 31, and 32) reviewed for weight loss. * The facility failed to ensure the RD's recommendations on 3/14/25, were followed up with the physician and addressed in the Nutrition IDT when Resident 4 had a severe weight loss of 15 lbs in seven days. This failure had the potential for Resident 4 not to receive the necessary intervention to prevent further weight loss. * The facility failed to ensure the RD and IDT analyzed and implemented the necessary interventions to address Resident 32's unplanned severe weight loss of 16 lbs which was equivalent to 8.33% in 21 days. In addition, the physician and resident and/or their representative were not notified of Resident 32's unplanned significant weight loss of 16 lbs, 8.33% between 2/7/25 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the GT placement check was performed prior to starting the resident's enteral feeding for one of one final sample resident reviewed for tube feeding (Resident 32). This failure had the potential for the residents to develop complications related to the GT care and management, including tube dislodgement. Findings: Review of the facility's P&P titled Enteral Feedings-Safety Precautions revised 12/2011 showed the section for Preventing Aspiration showing to check enteral tube placement prior to each feeding and administration of medication. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 12/2011 showed the section for Steps in the Procedure showing to verify placement of the tube as follows: - Observe for a change in the external tube length marked at the time of the initial insertion X-ray. - Observe for signs of respiratory distress (if applicable). - Auscultate:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for two of two sampled residents (final sample resident, Residents 356 and nonsampled resident, Resident 705) reviewed for respiratory care. * The facility failed to ensure the oxygen was administered as ordered by the physician to Resident 356. * The facility failed to ensure the nasal cannula tubing was dated and a storage bag was provided for Resident 705. These failures had the potential for these residents to not receive the appropriate respiratory care or developed respiratory infection which may negatively affect the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of the procedure is to provide guidelines for safe oxygen administration. Further review of the P&P showed to verify that there is a physician order for the procedure and to review the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41%. * LVN 1 did not administer Resident 34's metformin HCL (medication to lower the blood sugar) with meal or food as ordered. * LVN 1 administered Advil (pain reliver) 200 mg two tablets for Resident 44's pain level of 8 which was not a prescribed pain level for this pain medication. These failures had the potential to negatively impact the residents' health outcomes. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medication shall be administered in a safe and timely manner, and as prescribed. The medications must be administered in accordance with the orders, including any required time frame. 1. On 3/26/25 at 0827 hours, a medication administration observation for Resident 34 was conducted with LVN 1. Resident 34 had no breakfast tray on the overbed table. LVN 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications. * The facility failed to ensure Medication Cart A was maintained in a clean and sanitary manner. * The facility failed to ensure Medication Cart B was maintained in a clean and sanitary manner and the expired medication in the medication cart was disposed. * The facility failed to dispose of the expired medications in the Medication Storage Room. * The facility failed to store the oral and external medications separately in the Medication Storage Room. These failures had the potential to negatively impact the residents' well-being, for the medications to lose the stability and effectiveness, and medication errors. Findings: Review of the facility's P&P titled Drug Storage and Labeling (undated) showed the drugs and biologicals will be stored in a safe, secure and orderly fashion, and will be accessible only to the licensed nursing or pharmacy personnel.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the egg rolls and cream of rice during the puree preparation. * Residents 7, 706, 707, 756, and 758 (nonsampled residents) were not served a regular textured diet as ordered by the physician. * Resident 706 (nonsampled resident) was not served the appropriate serving portion as ordered by the physician * [NAME] 1 failed to use the correct scoop size to serve rice for Resident 33 (final sample resident). These failures had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the kitchen. Review of the facility's P&P titled Menu Planning dated 2023 showed the menus are planned to meet nutritional needs of resident in accordance with established national…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for two of 15 final sampled residents (Residents 4 and 33). * Resident 4's POLST failed to show documentation as to whether Resident 4 had formulated the advanced directive. * The facility failed to ensure Resident 33's peripheral IV catheter care was documented. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete. Findings: 1. Review of the facility's P&P titled Advance Directive revised 11/2019 showed once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to the members of the care plan team. The facility will also notify the attending physician of the advance directives so that, if necessary, the appropriate orders can be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the hospice and facility staff worked collaboratively together in the plan of care for one of one hospice resident (final sampled resident, Resident 1) as per the hospice contract agreement. This failure had the potential of Residents 1 to not receive hospice care as per the hospice contract agreement and P&P. Findings: Review of the facility's P&P titled Hospice Program revised 12/2011 showed when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions. Review of Hospice A's Services Agreement: Exhibit B (undated) showed for Nursing Services, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed as evidenced by: * The OTA failed to perform hand hygiene before and after assisting Resident 4 to the bathroom. * LVN 1 failed to perform hand hygiene before and after taking the resident's blood pressure, during the medication preparation and administration, and in between the medication administration for Residents 3 and 34. * LVN 7 failed to perform hand hygiene after removing her gloves and in between contacts with Resident 24's roommate and Resident 24. These failures posed the risk for the transmission of the communicable diseases to other residents in the facility. Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene dated 12/2012 showed the facility considers hand hygiene the primary means to prevent the spread of infection. Employees must wash their hands for at least fifteen (15) seconds using…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the kitchen's essential equipment in a clean and safe operating condition when: * The ice machine was not cleaned as per the manufacturer's guidelines for cleaning and sanitizing. * The low temperature dishwasher handles were missing covers and had brown discoloration. * The low temperature dishwasher machine was not operating as per the manufacturer's instructions. * The residents' dining room refrigerator temperature log was not monitored as per the facility's policy. There failures had the potential for the essential equipment to not function in the way it was intended, and exposed the residents to unsafe practices, which could lead to food borne illnesses for the residents. Findings: Review of the facility's census on 3/25/25, showed 57 of 59 residents received food from the kitchen. Review of the facility's P&P titled Sanitation dated 2023 showed the following: Policy: The Food & Nutrition Services Department shall have equipment of the type and in the amount…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to treat one of three sampled residents (Resident 2) with dignity when the staff removed her indwelling urinary Foley catheter. * The facility failed to get permission from Resident 2 for multiple staff to be present during the Foley catheter removal. This failure had the potential to negatively affect Resident 2's well-being. Findings: Review of the facility's P&P titled Resident Rights revised 10/2009 showed the Federal and state laws guarantee certain basic rights to all residents of this facility which includes to choose a physician and treatment, and participate in decisions and care planning. Our facility will make every effort to exercise his/her rights to assure the resident is always treated with respect, kindness, and dignity. Review of the facility's P&P Titled Quality of Life-Dignity revised 10/2009 showed the staff members shall promote, maintain, and protect the residents' privacy, including bodily privacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the medications were administered as ordered for one of three sampled residents (Resident 2). * The facility failed to ensure the medications scheduled for 0900 hours were administered to Resident 2timely. This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be administered within one hour of their prescribed time unless otherwise specified (for example before and after meal orders). Medical record review for Resident 2 was initiated on 11/19/24. Resident 2 was admitted to the facility on [DATE]. Resident 2 had a diagnosis of muscle spasms, hypertension, multiple sclerosis, and osteoarthritis. On 11/19/24 at 1005 hours, an interview was conducted with Resident 2. Resident 2 stated she had not received her knee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the blenders used for puree preparation were air dried prior to storing. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to offer and provide hand hygiene to the residents before and after meals. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the CMS-672 Resident Census and Conditions of Residents completed by the facility on 10/3/23, showed 54 of 57 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 23 final sampled residents (Resident 443) was assessed to self-administer his medications. This failure had the potential for Resident 443 to administer medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications revised 12/2012 showed the residents have the right to self-administer medications if the staff and practitioner have determined that it is clinically appropriate and safe for the resident to do so. Determination of a resident's ability to self-administer medications shall be documented in the resident's medical record. On 10/2/23 at 0924 hours, an observation and concurrent interview was conducted with Resident 443 and CNA 1. Resident 443 was observed with two medicine cups containing pink cream on the bedside table. Resident 443 stated the cream was for the inflamed skin between his groins. Resident 443 stated the nurse left the cream at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed and/or implemented for five of 23 final sampled residents (Residents 21, 29, 37, 344, and 543). * The facility failed to ensure the bilateral floor mats were implemented in accordance with Residents 21 and 37's care plan. * The facility failed to develop a comprehensive person-centered care plan to address the use of CPAP machine for Resident 29. * The facility failed to ensure to follow a plan of care intervention to monitor and document intake and output for Resident 344's use of suprapubic catheter. * The facility failed to initiate a care plan to address the use of duloxetine HCL (an antidepressant medication) and trazodone (an antidepressant medication and sleep aid) including specific behavioral manifestations to be monitored by staff for Resident 543 These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 23 final sampled residents (Resident 543) attained and maintained highest practicable physical well being. * The facility failed to ensure Resident 543's blood pressure and pulse rate were assessed and documented as ordered. * The facility failed to address Resident 543's complaints of constipation, notify physician of the change in condition, provide bowel regimen for constipation, and follow the care plan for pain medication and constipation monitoring. These failures had the potential to adversely affect the physical health and create the risk of not providing appropriate and consistent care to the resident. Findings: a. Review of the facility's P&P titled Administering Medications revised 12/2012 showed medications shall be administered in a safe and timely manner and as prescribed. Medical record review for Resident 543 was initiated on 10/3/23. Resident 543 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 23 final sampled residents (Residents 10, 21, and 37) remained free from accident hazards. *The facility failed to implement bilateral floor mats as per the physician's order and as care planned for Resident 37. *The facility failed to ensure the bilateral floor mats were implemented as per the care plan for Resident 21. *The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 10. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Review of the facility's P&P titled Falls and Fall Risk, Managing revised 12/2007, showed staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and to try to minimize complications from falling. Medical record review for Resident 37 was initiated on 10/2/23. Resident 37 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for five of 23 final sampled residents (Residents 10, 24, 29, 344, and 543) and one nonsampled resident (Resident 43). * The facility failed to administer oxygen therapy treatment as ordered by the physician for Resident 344. * The facility failed to ensure Resident 43's nebulizer mask was stored properly. * The facility failed to ensure Resident 29's CPAP mask was stored properly. * Resident 24 received continuous oxygen at 3 L/min via nasal cannula without a physician's order. * The facility to administer oxygen therapy as ordered by the physician for Resident 543. * The facility failed to ensure that nebulizer mask and tubing were changed and labeled as per the facility's policy for Resident 10. These failures had the potential risk for residents' respiratory equipment to become contaminated and negatively affect the residents' medical condition. Findings: Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the availability of the prescribed supplements for one nonsampled resident (Resident A). * Resident A had a physician's order for garlic supplement and glucosamine supplement. The licensed nurse was unable to administer the garlic and glucosamine supplements as ordered due to the unavailability of the supplements. This failure posed the risk for inhibiting the therapeutic effects of the supplements and had the potential to negatively affect the resident's health. Findings: Medical record review for Resident A was initiated on 10/2/23. Resident A was admitted to the facility on [DATE]. Review of Resident A's Order Summary Report showed a physician's order dated 9/26/23, to administer garlic tablet 1 mg orally once a day for supplement. Review of Resident A's Order Summary Report showed a physician's order dated 9/26/23, to administer a glucosamine capsule 500 mg orally twice a day for supplement. On 10/5/23 at 0809 hours, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from drug regimen review in August 2023 were acted upon for one of 23 final sampled residents (Resident 9). This failure placed the resident at risk for receiving unnecessary medications, increasing their risk for side effects. Findings: Review of the facility's P&P titled Medication Therapy revised date 4/2007 showed the Consultant Pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. The Physician will identify situations where medications should be tapered, discontinued, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of 23 final sampled residents (Residents 10 and 543) were free from the unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure Resident 543's episodes of behaviors for the use of duloxetine (medication used to treat depression) and Trazadone (medication used to treat depression and aid with sleep) were consistent with the physician's orders. * The facility failed to provide the non-pharmacological interventions to Resident 10's anxiety to minimize the Xanax and lorazepam use; failed to provide the physician's documentation to extend Resident 10's Xanax and lorazepam medications (psychotropic medications) after 14 days of PRN use; and failed to ensure Resident 10's episodes of behavior for the use of Xanax (antianxiety medication) were accurately monitored and documented in the MAR. These failures had the potential to negatively impact the residents' well-being.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41%. Two of two licensed nurses (LVNs 2 and 4) were found to have made errors during the medication administration observations. * Resident 10 had a physician's order to apply 2 grams of 1% Voltaren (pain relief gel); however, the LVN failed to utilize the dosing card to determine the dose of Voltaren administered to Resident 10. * Resident A had a physician's order for Pulmicort inhalation (corticosteroid medication) for hypoxia which was scheduled to be administered at 0900 hours; however, the LVN did not administer Resident A's Pulmicort until approximately 5 hours after the mediation was ordered to be administered. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed the medications must be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly two of four medication carts and failed to store resident biologicals and treatment supplies in a safe manner for one of one treatment cart. *The facility failed to ensure two medication carts (Medication Carts A & B) were kept locked when unattended by staff. * The facility failed to ensure medications were not left unattended on top of Medication Cart B. * The facility's treatment cart was observed with several unpackaged gauze pads lying on top of a pair of scissors and Calmoseptine ointment stored inside of a plastic cup. These failures posed the risk of unauthorized persons having access to the medications and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2007 showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the physician was notified regarding laboratory services were not performed as ordered and abnormal laboratory test results were reported for two of 23 final sampled residents (Residents 344 and 543). * The facility failed to ensure the physician was notified of laboratory test not performed as ordered for Resident 344. * The facility failed to ensure the physician was notified of the abnormal lab results and documented in Resident 543's medical record. These failures had the potential to adversely affect the residents' physical health. Findings: Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed it is the policy of the facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant, or Nurse Practitioner. Laboratory and radiology services will be arranged as ordered. Results of laboratory, radiological, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 23 final sampled residents (Resident 343) was provided a prescribed therapeutic diet. This failure posed the risk of Resident 343's nutrition needs not being met. Findings: Review of the facility's P&P titled Nutrition Care: Diet Orders for New Admission, Diet Changes, Nothing by Mouth (NPO), or Hold Meals (undated) showed all residents/patients will have a written diet order on admission which has been prescribed by the physician. Verbal telephone orders may be received and recorded by a registered dietitian and will be signed by the prescriber. On 10/2/23 at 1229 hours, during the dining observation, Resident 343 stated she had a thyroid surgery in the past. Resident 343 stated she did not eat most of her protein in her plate because it was harder for her to swallow, or the food got stuck in her throat. Resident 343's meal card ticket showed a regular soft diet and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the rehabilitation services for one of 23 final sampled residents (Resident 345). * The facility failed to ensure Resident 345 was provided RNA services for AROM exercises to bilateral upper and lower extremities as per the physician's orders. This failure had the potential for Resident 345 to decline in the ROM functions and mobility. Findings: Review of the facility's P&P titled Quality of Care: RNA, Restorative Nursing, and Documentation revised 2/2022 showed it is the policy of the facility that Restorative Nursing shall be provided to a resident upon recommendation by the rehabilitation department to meet the resident restorative nursing care need. Physician's orders are to be obtained when a resident is to participate in the facility's restorative nursing program for ambulation or range of motion (ROM). The staff providing the program shall document that the RNA program is provided by documenting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 23 final sampled residents (Residents 10, 31, 344, and 543) were complete and accurate. * The facility failed to ensure the indwelling urinary catheter care was recorded for Resident 344. * Resident 10's physician's order for Pilocarpine 1% ophthalmic solution contained a conflicting administration frequency. * The facility failed to record the edema assessment for Resident 31. * Resident 31's medical record contained a physician's order for another resident (Resident 44). * The facility failed to ensure Resident 543's POLST form was accurate and signed by the physician. * The facility failed to ensure Resident 543's wound treatments were documented in the TAR. These failures had the potential to not providing necessary care and services to these residents as their medical information was inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and prevent the transmission of diseases and infections to all residents; and fail to implement safe and sanitary infection control practices for one of 23 final sampled residents (Resident 393). * The facility failed to ensure the personal items were not on the clean sorting table in the laundry. * The facility failed to ensure Resident 393's urinary drainage bag and urine meter drainage container (used to measure and drain urine when emptying) were not touching the floor. These failures posed the risk for transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Laundry revised 2/2022 showed it is the policy of the facility that careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious disease to other staff members, residents, and visitors. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.