Beach Street Health And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food storage practices were adhered to in order to prevent the outbreak of foodborne illnesses. The findings include: During an initial tour of the kitchen with the Certified Dietary Manager on 9/23/2024, beginning at 11:00 AM, the following was observed: Three (3) salads prepared on individual plates with no date or label in reach in refrigerator #1. Two (2) undated cut halves of honey dew melon, 2 undated cut quarter slices of honey dew melon and 1 undated cut half of a watermelon without dates stored in the produce refrigerator. One (1) undated and unlabeled bag of diced vegetables stored in the produce refrigerator. Five (5) undated and unlabeled 5-ounce containers of pureed fruit in the pastry freezer. One (1) uncovered, undated and unlabeled picture of a red drink. Two (2) undated and unlabeled pitchers of beverages stored underneath raw meat products in the meat freezer. During an interview on 9/23/2024 beginning at 11:00 AM, the Certified Dietary Manager acknowledged 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 observation, interview, and policy and procedure review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection, by 1) failing to perform appropriate hand hygiene during medication administration for four (Residents #51, #80, #238, and #71) of eight residents observed for medication administration, and 2) failed to follow acceptable standards of care for enhanced barrier precautions for a central venous catheter for one (Resident #237) resident during medication administration from a total survey sample of 37 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. The findings include: 1. During an observation of medication administration on 9/23/2024 at 12:03 PM, Staff B, Registered Nurse (RN), returned to the medication cart from the nurses station, removed medication cart keys from their pocket, unlocked the medication cart, activated the computer and typed…

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 and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, by not ensuring proper repair of hand rails in the north and south wings of the facility. The findings include: During an observation on 9/23/2024 at 11:59 AM of railings on South [NAME] wing, four caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:10 AM of railings on North [NAME] wing, three caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:40 AM with the Director of Maintenance, he confirmed the railings in South [NAME] and North [NAME] wing had missing caps with jagged metal exposed. During an interview with the Administrator on 9/24/2024 at 1:17 PM, the administrator stated, I know all of these need to be fixed. Review of the facilities policy and procedure titled Safe and Homelike…

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 that residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were referred for a Level II evaluation and examination for two (Residents #67 and #60) of 37 residents sampled for Preadmission Screening and Resident Review (PASARR). The findings include: 1. Review of Resident #67's PASARR dated 5/10/22 documented a negative Level 1 with no mental illness or intellectual disability listed. Review of the admission record for Resident #67 revealed an initial admission date of 4/13/22 and a re-admission date of 5/10/22. Diagnosis listed on the admission record included other specified anxiety disorders dated 5/5/23. Review of the psychiatry note for Resident #67 dated 7/10/23 read, This is a [AGE] year-old patient with past history of anxiety and insomnia. On 5/5/23 patient was anxious. Patient was presented with compulsive behaviors of touching and playing with stomach. Patient reported itching…

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 each resident was screened for a mental disorder or intellectual disability prior to admission to ensure those individual identified with mental disorders or intellectual disabilities are evaluated and receive care and services in the most appropriate setting for one (Resident #4) out of 37 residents sampled for Preadmission Screening and Resident Review (PASARR). The findings include: Review of the admission record for Resident #4 documented an initial admission date of 1/2/2018 with readmission dates following hospital stays on 12/28/23 and 3/29/24. Diagnoses included cerebral palsy unspecified (onset date 1/2/2018), generalized anxiety disorder (onset date 10/26/2020), bipolar disorder unspecified (onset date 1/2/2018), and major depressive disorder (onset date 5/20/2022). Review of the PASARR Level 1 screening for Resident #4 dated 12/28/2023 did not document anxiety disorder, bipolar disorder, depressive disorder or a related condition of cerebral palsy. The Level I screening for Resident #4 documented on page…

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 staff failed to provide central venous catheter dressing changes as ordered in accordance with professional standards of practice for one (Resident # 237) out of one resident reviewed with a peripherally inserted central catheter, out of a total sample of 37 residents. The findings include: During an observation on 9/23/2024 at 10:25 AM, Resident #237 was sitting in bed with a right arm single lumen peripherally inserted central catheter (PICC) line. The transparent dressing was lifting up at the edges, exposing the insertion site. The date on the dressing was 9/10/2024. During an interview on 9/23/2024 at 10:30 AM, Resident #237 stated, They have not changed this (the PICC line dressing) since I was admitted , I get antibiotics for a blood infection. I have not been offered a dressing change. During an observation on 9/23/2024 at 2:30 PM, Resident # 237 was observed sitting up in bed with a right upper arm single lumen PICC line with date 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 record review, the facility staff failed to ensure that oxygen was administered consistent with professional standards of practice for two (Residents #80 and #187) out of four residents reviewed for respiratory care, from a total of 37 residents sampled. The findings include: 1. Review of Resident #80's admission record revealed the following diagnoses: cerebral infarction, unspecified (a stroke), acute respiratory failure with hypoxia (low levels of oxygen in the blood), acute pulmonary edema (fluid in the lungs), essential (primary) hypertension (high blood pressure), major depressive disorder, hypothyroidism, unspecified, and hemiplegia (paralysis of one side of the body), unspecified affecting right dominant side. Review of Resident #80's physician orders dated 4/8/24 reads, Oxygen at 2 liters/ min (minute) via nasal cannula with Humidification PRN (pro re nata) [as needed]-to keep O2 (oxygen) sat (saturation) above 90% as needed for SOB (shortness of breath). 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.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner to limit unauthorized access to medications for three (Residents #78, #74, and #6) out of six residents reviewed for medication storage. The findings include: 1. During an observation on 9/23/2024 at 12:24 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an interview on 9/23/2024 at 12:24 PM Resident #78 stated I take one tablet every night and they know that I have it and take it. During an observation on 9/23/2024 at 2:50 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation on 9/24/2024 at 07:55 AM of Resident #78's room one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation in Resident #78's room on 9/24/2024…

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 observations and interviews, the facility failed to keep the kitchen safe from potential food contamination due to a ceiling area under which food was being prepared and distributed, having gaps and hanging tape on it. The findings include: On 4/13/21 at 1:40 pm, the kitchen's ceiling was observed with open areas and gaps. Some piping was visible. There was tape hanging from an area between ceiling tiles. One ceiling tile had a plastic, sheet-like covering that was hanging loose and had opening on one side where it had been taped up. On 4/15/21 at 11:30 am, the same observations were made of the kitchen's ceiling with no changes. Staff were observed working under open areas of the ceiling while preparing food. The areas of ceiling where gaps were observed have the potential to contaminate foods with dust/debris. On 4/16/21 at 11:50 am, the same observations were made of the kitchen's ceiling with no changes made. The residents' food was being prepared under open areas of ceiling that had gaps in it where dirt/dust or debris could fall into resident's food or food tray. 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, and interviews, the facility failed to ensure a safe, functional, sanitary environment for 41 of 72 residents by not replacing missing tiles, and not repairing an area on the wall which was covered with gray substance on one of two nursing units. The findings include: Observation of the shower room on South wing on 4/13/21 at 11:00 AM revealed green tiles missing around the sink area with a large gray area on the wall near venting unit with multiple white tiles missing. (photographic evidence obtained) Additional observations of the shower room on South wing were conducted on 4/14/21, 4/15/21 and 4/16/21. The shower room continued to have missing tiles with a large gray area on the wall. An interview was conducted with Employee B, Maintenance Assistant, at 9:10 AM on 4/16/21 concerning the observations in the shower room on South wing. He reported the sink was replaced in the shower room at least 6 months ago due to a leak and the tile was not replaced. He reported there was a leak and the tiles were taken down in order to reach the pipes and the leak. Employee…

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 record review and interview, the facility failed to issue proper notices to inform each resident of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. This affected one of three residents reviewed. (Resident #22) The findings include: On 4/14/2021 at 3:03pm, the Business Office Manager provided the survey team with three incomplete Beneficiary Notice forms. She inquired about possible changes in the Skilled Nursing Care Advanced Beneficiary Notice (ABN), Centers for Medicare and Medicaid (CMS) form 10055. She was advised to provide the documentation that was given to the residents selected for the beneficiary notice task. On 4/14/2021 at 3:21 pm, the Social Services Director provided the survey team with incomplete beneficiary notice forms. The ABNs, CMS forms 10055, were incomplete and not signed by the residents, and there were no Notice of Medicare Non-Coverage (NOMNC), CMS forms 10123 found for the residents. The form for Resident #22 indicated…

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 record review and staff interview the facility failed to ensure an allowable diagnosis for the use of antipsychotic medication and to obtain new physician orders to extend duration beyond 14 days for an as needed psychotropic medication for 1 of 5 residents sampled for unnecessary medications from a total sample of 38. (Resident #23) The findings include: Record review for Resident #23 revealed a [AGE] year old male admitted on [DATE] and readmitted from the hospital on 3/30/21. His diagnoses included acute and chronic respiratory failure with hypercapnia, diabetes, osteomyelitis, major depressive disorder and anxiety. He was alert and oriented and required extensive assistance with activities of daily living. Upon admission he was ordered the medication Seroquel (antipsychotic) 25 mg at bedtime for anxiety and Xanax (antianxiety) 0.5 mg every eight hours, as needed for anxiety. Review of the Medication Administration Record (MAR) revealed Xanax 0.5 mg was ordered 3/30/21 and had not been used as 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.

Based on observation and staff interview, the facility failed to ensure oral medications and external biological and topical treatments were kept in separate areas of the medication room for 1 of 2 medication rooms, medications were stored under proper temperature control, and expired medications were removed from one of four medication carts. The findings include: During an observation of the medication room on the the south wing on 4/16/21 at 12:15pm, the following was found: over the counter oral medications (milk of magnesia, Prostat, Promod) were commingled on the shelves with wound cleaners, Betadine (antiseptic external solution), and Hibiclens (solution for cleaning wounds). An interview with the unit manager at 12:20pm confirmed the oral medications were not separated from external solutions. Observation of the medication refrigerator on the north wing at 12:30pm with the unit manager (UM) found the temperature was at 38 degrees and the freezer section was totally engulfed with ice and the bottom shelf was very soiled. The UM confirmed the temperature and the refrigerator…

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.