Beachside Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were stored properly on one of two medication storage rooms. The facility failed to:1. Ensure Resident 40's discontinued Risperidone (antipsychotic -[a type of medication prescribed to treat mental health problem]) was disposed of and not kept in a box labeled extra medicines in the Medication Storage room.2. Ensure expired hemorrhoidal ointment (medicated jelly or paste used to soothe swollen, inflamed veins in the rectal area) was not stored in the medication storage room.These failures resulted in expired and discontinued medications being available in the medication storage area, increasing the risk of medication administration error and having the potential to unintentional dispensing of expired or discontinued medications to residents.Findings:1. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including…

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 record review, the facility failed to ensure food service staff were competent in reading test strips (a small, treated piece of paper or plastic designed to interact with a sample and reveal the presence, absence, or concentration of specific chemical substances) used for testing chlorine (deep cleaning and sanitizing agent) in the dishwashing machine.This failure had the potential to put residents at risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) due to inability to read and interpret the test strips used for testing the correct range of sanitizer solutions for the dishwashing machine.Findings:During a concurrent observation and interview with Dietary Aide (DA)1, DA 1 demonstrated on how to check the amount of chlorine in the dishwashing machine after the final rinse by dipping a test strip in the water and comparing the test strip to the color chart of the test strip container. DA 1 stated the strip read 50 parts per million (PPM- unit of measurement) and the kitchen staff follows 50-200 PPM for…

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 record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to prevent or reduce the risk of contracture (loss of motion of a joint associated with stiffness and joint deformity) development for two of seven sampled residents (Residents 14 and 33) who were identified as having range of motion (ROM, full movement potential of a joint) limitations and were at high risk for contracture development. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 14 and 33. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore…

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 b. During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marker by tremor, muscular rigidity, and slow, imprecise movement) and dementia (a progressive state of decline in mental abilities). During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severe cognitive impairment and was dependent (helper does all the effort) with ADL's. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder like depression {mood disorder that causes persistent feelings of sadness and loss of interest} and mania {mental state of an extreme high or depressive lows} and Parkinson's disease (a progressive disease of the nervous system marked…

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 record review, the facility failed to provide treatments and services to one of seven sampled residents (Resident 14) to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) by failing to: 1.Ensure Resident 14's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, 12/11/2024, and 3/13/2025, included the assessment of Resident 14's left knee ROM. 2.Ensure Resident 14's Quarterly JMA, dated 6/2024, was completed. These deficient practices had the potential to result in missed opportunities for identifications of ROM declines and cause Resident 14 to have a decline in overall physical functioning and ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to 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, and record review, the facility failed to ensure the facility's Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) were competent in providing quarterly Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) affecting one of seven sampled residents (Resident 14) with limited range of motion (ROM, full movement potential of a joint). This deficient practice resulted in multiple missed assessments of Resident 14's left knee, failure to identify inaccurate documentation and assessment of Resident 14's left leg, missed opportunities to identify and report ROM decline, and had the potential to lead to ROM decline and contracture (loss of motion of a joint associated with stiffness and joint deformity) development. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including 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.

Based on observation, interview and record review, the facility failed to: 1. Ensure open bag of frozen sausages was stored properly in the freezer. 2. Ensure freezer temperature was maintained at 0-degree Fahrenheit (F-unit of measurement) while frozen vegetables were stored. 3. Ensure gloves were used by kitchen staff when serving cooked food during tray line. 4. Ensure proper donning of glove and handwashing was observed when the [NAME] switched tasks from tray line to prepare food in the microwave. These failures had the potential to put residents at risk for food-borne illnesses ( any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and affect the quality of food. Findings: 1.During an initial kitchen observation and interview on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), an open bag of frozen sausages was inside an open box. Observed the frozen sausages had ice crystals on the surfaces.DM stated the open bag of frozen sausages should be stored in a sealed plastic bag. During an interview on 4/9/2025, at 1:30 p.m. with…

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 record review, the facility failed to ensure two of seven sampled resident's (Residents 14 and 19) medical records were accurately documented when: a.Resident 14's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, 12/11/2024, and 3/13/2025, inaccurately indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee) instead of the correct diagnosis of a left below knee amputation (BKA, surgical removal of a limb below the level of the knee involving the removal of the foot and ankle joint). b.Resident 19's Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) physician's order inaccurately indicated for RNA to use a two-wheeled walker (mobility aid with wheels on the front two legs of the device) for walking exercises with Resident 19 instead of a platform walker…

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 record review, the facility failed to maintain and observe infection control practices by failing to: a.Change and label tube feeding water bag for Resident 28. b.Perform hand hygiene during wound care dressing change for Resident 56. c.Ensure Physical Therapist 1 (PT 1) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assessing Resident 14's left leg which required direct contact with Resident 14 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed reduce the transmission of multi-drug-resistant organisms). d. Licensed Vocational Nurse (LVN) 5 failed to sanitize blood pressure cuff in between residents. e. Ensure sanitary handling and transport of soiled linens. These deficient practice had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from…

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 record review, the facility failed to ensure reach in freezer for frozen vegetables and freezer for frozen meat products in the kitchen were maintained and kept in a safe and operating condition by failing to: 1. Follow their policy and procedure titled Freezer Storage regarding maintaining a temperature of 0-degree Fahrenheit (F- unit of measurement) or lower . This failure had the potential to expose residents at risk for food-borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites). Findings: During an initial kitchen tour observation on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), DM verified the internal thermometer of the reach in freezer for frozen vegetables was reading at 10 degrees Fahrenheit (F- unit of measurement) and the reach in freezer for meat products was reading at 24 degrees F. DM stated the kitchen personnel just removed some food items from the freezers that was why the temperatures are not 0-degree F on both freezers. During an interview on 4/8/2025, 2:15 p.m. with an…

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 and record review, the facility failed to secure the personal belongings for one of six sampled residents (Resident 39) by misplacing Resident 39's phone charger, wheelchair, and clothes. This failure had the potential to negatively affect the Resident 39's psychosocial well-being. Findings: During a review of Resident 39's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included irritable bowel syndrome ( common condition that affects the digestive system causing abdominal pain, bloating, and changes in bowel habits including diarrhea or constipation or both), hematemesis (vomiting of blood)sepsis (a life-threatening blood infection),and muscle weakness. During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 3/30/2025, the MDS indicated the resident's cognition (thought process) is intact and required substantial/ maximal assistance (helper does…

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 and record review, the facility failed to ensure a preadmission screening and annual review of a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was accurately documented for two of four reviewed residents (Residents 38 and 57). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident 38 and 57. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility 12/18/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 4/2/2025, the MDS…

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 and record review, the facility failed to identify and address one of four sampled residents (Resident 53) behavioral health needs by failing: A. to ensure Brief Trauma Screening Questionnaire (tool used to assess an individual's potential exposure to traumatic events and their current PTSD symptoms and this tool is used to help identify individuals who may need further assessment or support for trauma) for Resident 53 who had a diagnosis of Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) was assessed and screened properly by social service personnel. This failure had the potential for Resident 53 for not receiving appropriate care to meet his behavioral needs. Findings: During a review of Resident 53's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included PTSD, dementia( progressive…

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 interview and record review, the facility's Quality Assessment and Assurance (QAA) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification. This deficient practice resulted in the facility to have repeat deficiencies in comprehensive resident centered care plans, competent nursing staff, safe operating equipment, and the prevention of a decrease in range of motion (ROM- full movement potential of a joint). Findings: During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies in comprehensive resident centered care plans, competent nursing staff, safe operating equipment, and the prevention of a decrease in range of motion (ROM). During a concurrent interview and record review on 4/11/2025 at with the Director of Nursing (DON), the DON stated she will continue to work on and make further changes for the issues that were still areas of concerns. The DON stated they…

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 and record review, the facility failed to follow up on and document not administering a consented pneumococcal vaccine (a vaccine for a bacterial infection that can cause a serious lung, brain, or blood infection) for one out of three residents (Resident 1). This deficient practice resulted in Resident 1 potentially contracting pneumonia (a lung infection). Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, abnormalities with gait (a person ' s manner of walking), mobility (the ability to move freely or lack thereof), and dysphagia (difficulty swallowing). During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/8/2024, the MDS indicated Resident 1 ' s cognition (ability to…

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 and record review, the facility failed to ensure a resident (Resident 1), who was receiving renal dialysis (a procedure which removes excess water, toxins, and solutes from the blood when the kidneys are no longer naturally able to do so) and received medications to treat elevated heart rate and blood pressure, primary care doctor (MD 1) was informed after refusing dialysis on 9/5/2024 and 9/10/2024 and refusing medication on 9/2/2024, 9/3/2024, 9/4/2024, 9/10/2024, 9/11/2024, and 9/12/2024 for one of three sampled residents. These failures resulted in Resident 1 ' s MD 1 being unaware of Resident 1 ' s refusal of medication and dialysis treatments and had the potential to cause a delay in medical intervention by MD 1. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including end stage renal disease (a permanent condition where…

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 record review, the facility failed to maintain and enhance the resident ' s dignity by prohibiting the use of motorized wheelchairs in the facility for two of three sampled residents (Resident 1 and 2). This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing. Findings: a. During a review of Resident 1 ' s Face Sheet (admission record), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (immobility of one side of the body) and hemiparesis (muscle weakness on one side) following cerebral infarction (stroke: cluster of brain cells dying due to not getting enough blood) affecting right dominant (hand instinctively used) side, and idiopathic peripheral autonomic neuropathy (never disorder that affects the functions of digestion, heart, and bladder). During a review of Resident 1 ' s Minimum Data Set [(MDS) a standardized assessment 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.

Based on observation, interview, and record review, the facility failed to ensure the microwave in the rehabilitation gym (rehab gym) was not used to store plastic utensils, plastic straws, and paper plates in the microwave cavity (empty space) and was used for it was intended purpose and in accordance with manufacturer's guidelines. This failure had the potential to cause burns, electric shock, and injury to any staff member, resident, or visitor in the facility. Findings: During a concurrent observation and interview on 4/18/2024 at 11:55 a.m., in the rehab gym, a white microwave was sitting on a table near the wall with plastic utensils, plastic straws, and a stack of paper plates stored inside the microwave cavity. The Director of Rehabilitation (DOR) stated the microwave was in working order and was used as a storage unit to hold utensils, straws, and paper plates when not in use. The DOR stated the purpose of the microwave was to heat food and items such as utensils, straws, and paper plates should not be stored in the microwave cavity because it was unsafe and could cause…

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 record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of four sampled residents (Resident 39) by: 1. Failing to provide ADL care for Resident 39 by emptying the urinal timely. Resident 39's urinal filled with urine and was left on the resident's bedside table. This failure resulted in Resident 39 feeling embarrassed and had the potential to lower Resident 39's self-esteem. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including human immune deficiency virus ([HIV], a virus that attacks the body's immune system), atrial fibrillation (irregular heart rhythm that begins in your heart's upper chambers),and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses a sugar as a fuel). During a review…

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 record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to improve, maintain, or prevent a further decline in range of motion (ROM, full movement potential of a joint) for one of seven sampled residents (Resident 25) who was identified as having severe ROM limitations in the left shoulder upon admission and ROM concerns. This failure had the potential to negatively affect the delivery of necessary care and services for Resident 25, lead to contracture (loss of motion of a joint) development, and a decline in overall physical functioning such as the ability to move, eat and dress. Findings: During a review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (reduced circulation of blood to a body part due to a narrowed or blocked blood vessel), acquired absence of the right leg below the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility failed to ensure one of four sampled residents (Resident 50) received care and services to perform activities of daily living (ADLs, basic activities such as eating, dressing, toileting) when facility failed to: 1.Provide shower/bed bath to Resident 50 since resident's re-admission to the facility on 2/28/2024. 2.Provide grooming including haircuts, and nail trimming since Resident 50's re-admission to the facility on 2/28/2024. 3. Ensure Resident 50's refusal of care including showers and personal hygiene was care planned. These failures resulted in Resident 50's experienced poor hygiene, appeared disheveled, loss of self-esteem, felt embarrassed and look unkempt. Findings: During a review of Resident 50's admission Records indicated Resident 50 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), end…

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 record review, the facility failed to provide treatments and services to maintain and limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) for one of seven sampled residents (Resident 25) by failing to ensure the following: a.Resident 25 received treatment and services to maintain and prevent a decline in ROM of both arms. b.Director of Rehabilitation (DOR) assessed Resident 25's both arms before establishing an RNA program for ROM exercises to Resident 25's both arms. These failures led to the decline in joint range of motion of Resident 25's both hands and right shoulder and had the potential to lead to contractures (loss of motion of a joint associated with stiffness and joint deformity), decline in physical functioning such as the ability to eat and dress, and injury. Findings: During a review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including…

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 interview and record review, the facility failed to ensure the facility's Certified Nursing Assistants (CNAs) were provided the appropriate abuse and dementia training for one of seven sampled staff Certified Nursing assistant 3 (CNA 3). This failure had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings: During a concurrent interview and record review on 4/19/2024 at 11:31 a.m. with the Director of Staff Development (DSD), the DSD stated when there was a new hire, the staff will have an orientation and will complete various trainings such as abuse (cruel and violent treatment of a person) and dementia (impaired ability to remember, think, or make decisions) training prior to starting. DSD stated the required training for dementia training was one hour and abuse training was two hours annually. DSD stated there was a pre and posttest after an abuse training, but they do not…

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 interview and record review, the facility failed to ensure an annual performance evaluation (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) was performed every year for one Certified Nursing Assistant (CNA) 2. This failure had the potential for the facility not be able to assess the skills necessary for CNA 2 to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings: During a concurrent interview and record review on 4/19/2024 at 12:14 p.m. with Director of Staff Development (DSD), DSD stated staff performance evaluations were done yearly. DSD stated CNA 2 has been working at the facility since 2019 and her last employee evaluation was on 4/19/2022. DSD stated the employee evaluation were used to measure staff quality of work, knowledge, and skills. DSD stated CNA 2 employee evaluation was not done for 2023. DSD…

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 and record review, the facility's nursing staff failed to ensure one of one sampled resident (Resident 74) received antibiotic (treat infection) medication as prescribed by the physician in a timely manner. This failure had the potential to result in ineffective treatment of Methicillin-resistant Staphylococcus aureus Bacteria (MRSA: group of gram-positive bacteria that is responsible for several difficult-to-treat infections) in the blood. Findings: During a review of Resident admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including acute osteomyelitis (serious infection of the bone that developed rapidly) on right ankle and foot, MRSA infection, Type II diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), chronic kidney disease (CKD: damaged kidneys that cannot filter blood and waste), and chronic obstructive pulmonary disease (COPD: group…

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 interview and record review the facility failed to ensure one of six sampled resident's (Resident 1's) pain level was documented prior to administering Morphine Sulfate (a narcotic substance that dull the senses and relieve pain and can be highly addicting) and Methadone (a powerful drug used for pain relief) from 12/7/2023 to 12/12/2023 and failed to document Resident 1's pain level every shift from 12/7/2023 to 12/ 12/2023. These deficient practices had the potential to negatively affect Resident 1's pain management regimen. Findings: During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted at the facility on 12/7/2023 with a diagnosis that included atherosclerosis of the aorta (progressive buildup of plaque in the largest artery in the body), liver cirrhosis (a condition where the liver, organ that filters waste and toxins from the blood, is permanently damaged), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems to the body) and palliative care (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 and record review the facility failed to ensure the responsible party (RP) for one of three sampled residents was informed of the risks and benefits before reducing Resident 1 ' s psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: During a review of Resident 1 ' s face sheet (admission record), the face sheet indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses that include Parkinson ' s disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), major depressive disorder (mental disorder characterized by loose of interest in daily life) , anxiety (severe mental disorder characterized by extreme worry), dementia (problems with memory, thinking, 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.

Based on interview and record review the facility failed to document a completed facility wide assessment for 86 of 90 residents by: a. Failing to ensure Infection Preventionist Nurse (IPN) involvement in completing the assessment and failing to include the need for an IPN in the facility. b. Failing to describe the resident population profile by not indicating the average daily resident census (number of residents in the facility), the residents' acuity (allocation of clinical expertise and caregiver resources needed to provide care) levels. c. Failing to describe ethnic, cultural, and religious factors that affect the type of care needed for the facility's resident population. These deficient practices had a potential to result in the provision of incompetent care and services to the facility's resident population. Findings: During a record review of the Facility assessment tool, revised 10/19/2022, the tool indicated the following: a. The IPN did not participate in completing the tool on from 10/13/ 2022 to 10/18/2022. b. The average daily resident census and the residents'…

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 record review the facility failed to implement Coronavirus disease ([COVID-19] a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) outbreak response measures (acts and procedures to minimize the spread of a disease) as evidenced by the facility failure to: a.Ensure two of two Certified Nursing Assistants (CNA 3 and 4) doffed (took off) the N95 mask (a respiratory protective device designed to achieve a very close facial fit for effective filtration of airborne particles) they wore inside the isolation (rooms designated to keep residents, who have certain medical conditions, such as infections, separate from other people while they receive medical care) rooms of Covid-19 positive residents (Resident 4 and 5) prior to exiting the resident's room and donned (put on) a clean N95 mask after exiting residents' isolation rooms and walking in the hallway of the resident care areas. b.Screen one of one…

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 and record review facility failed to ensure one out of five residents (Resident 11) received the pneumococcal vaccine (medication to protect against pneumonia [infection of the lungs]) after consent was obtained on 11/28/2022; and the facility failed to ensure two of five sampled residents (Resident 12, and 13) were offered pneumococcal vaccination yearly after refusal. These deficient practices placed three residents at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: a. During a record review of Resident's 11 admission record, the admission record indicated Resident 11 was admitted to the facility on [DATE] and re- admitted on [DATE] with diagnoses that included diabetes mellitus (disease that causes human immunodeficiency virus (HIV- virus [germ] that attacks the body's immune system[way the body protects against outside invaders]), and hypertensive heart disease ( problems with the heart that can cause high blood pressure [measure of how…

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 and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 transcribed (write down) and carried out the physician order for Augmentin (antibiotic [medicine that fight infection]) and Loratadine (medication to treat allergy symptom) immediately after receiving the order on 10/21/2023 at 7:35 a.m. for one of three sampled resident (Resident 8). The deficient practice resulted in a more than six-hour delay of care, treatment, and relief of symptoms (headache and right cheek pain) for Resident 8. Findings: During a review of Resident 8's admission Record (Face Sheet), the Face Sheet indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including COVID 19 (a highly contagious infection, caused by a virus [germ]that can easily spread from person to person), atrial fibrillation (irregular heart beat), and essential hypertension (high blood pressure [a measure of how forceful the blood pumps in the body]) During a review of Resident 1's Minimum Data Set…

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.