Serenity Bay Nursing And Rehabilitation Center

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included. 1) During the initial kitchen/food service observation tour conducted on 06/17/2024 at 9:00 AM accompanied with the facility's Foods Service Director (FSD) and Registered Dietitian (RD), the following were noted: a) There was a large leak in the ceiling area located in front of the steam table and milk cooler. Further noted that there was an accumulation of water on the floor beneath the leak area. It was revealed by the Registered Dietitian that the leak occurred a few days ago. It was discussed that there was the potential for the contamination of food, equipment, and staff from the dripping of contaminated water. It was requested that the floor area underneath the leak be repaired immediately and to stop any food, staff and equipment from going under the leak area. b) Observation noted a ceiling mounted air-conditioning vent located over the steam table…

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 it was determined that the facility failed to dispose of garbage and refuse properly. The findings included: Observation of the garbage/dumpster area located outside at the rear of the facility on 06/17/2024 at 9 :15 AM and accompanied with the facility's Registered Dietitian, the following were noted: (a) The dumpster was noted to be overflowing and that resulted in the lids (2) being unable to be closed. Broken bags of garbage/trash were noted to be within the open dumpster cavity and falling down onto the ground area in front of the dumpster. (b) Due to the overflowing dumpster addition bags (30) of trash /garbage and nursing waste was noted to be stored on the ground area approximately 10 feet from the dumpster. Numerous bags were noted to be ripped open resulting in trash, garbage, and soiled PPE supplies (gloves, gowns, etc.) to be strewn around the ground area in front of the bags. c) Interview with the Administrator following the 06/17/24 tour noted to state that there was recent flooding in the area resulting in delay of routine trash…

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 reviews and interviews, the facility failed to obtain orders that accurately reflected code status for one (Resident #39) out of two residents reviewed for Advanced Directives. The findings included: Resident #39 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly Minimum Data Set, dated [DATE], Resident #39 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #39's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Depression, difficulty in walking, Unsteadiness on feet, Lack of Coordination, Muscle weakness, History of falling, Idiopathic pulmonary hemosiderosis, Personal history of disease of the circulatory system. Review of the resident's electronic health record revealed that there was no determination made regarding a code status for the resident. During an interview, on [DATE] at 9:02 AM, with Staff L, Unit Manager,…

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 interviews and record reviews the facility failed to ensure accuracy of medical personnel title for 1 of 29 sampled residents (Resident #32). The findings included: Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnosis including: Disorganized Schizophrenia, Other Psychotic Disorder Not Due to a Substance or Known Physiological Condition and Major Depressive Disorder. Review of the Minimum Data Set for Resident #32 dated 03/27/2024 revealed in section C for Cognitive Pattern documented a Brief Interview of Mental Status score of 15 out of indicating a cognitive response. During an interview conducted on 06/20/2024 at 9:45 AM with the Director of Nursing (DON) revealed she has worked at the facility since beginning of May 2024. When asked when Resident #32 was last seen by a physician, she reported it was 12/28/2023 by Staff G (later discovered to be a Nurse Practitioner). When asked what kind of physician it was that had seen the resident on…

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 observations, interviews and record reviews, the facility failed to develop and implement care plans for the use of bed rails for 3 of 3 residents reviewed for bed rails, Residents #54, 5, and 120. The facility failed to develop and implement a care plan for a urinary catheter for 1 (Resident #7) of 1 resident reviewed for catheter. The findings included: The facility's policy, Proper use of Bed Rails, implemented 05/01/2023, documented: Ongoing Monitoring and Supervision. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan . During an interview, on 06/20/2024 at 1:50 PM, with Staff N, MDS (Minimum Data Set) Coordinator, when asked about the lack of care plan for Resident #54's bed rails, the MDS Coordinator stated that Restorative was responsible for initiating care plans for bed rails. During 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 observations, interviews and record reviews, the facility failed to apply splint devices as ordered to prevent further decrease in range of motion for 1 of 1 resident reviewed, Resident #39. The findings included: Resident #39 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #39 had a Brief Interview for Mental Status score of 10, indicating that the resident was moderately cognitively impaired. The MDS documented that Resident #39 had bilateral impairments to upper and lower extremities and was dependent upon staff for all activities of daily living (ADLs). Resident #39's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Depression, difficulty in walking, Unsteadiness on feet, Lack of Coordination, Muscle weakness, History of falling, Idiopathic pulmonary hemosiderosis, Personal history of disease of the circulatory system. Resident…

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 observations, interviews, and record review, the facility failed to obtain physician's orders for an Indwelling urinary catheter and properly document the care for prevention of urinary tract infections for 1 out of 2 residents reviewed for bladder incontinence with an Indwelling Catheter (Resident #7). The findings included: During an observation conducted on 06/17/2024 at 10:31 AM, Resident #7 was noted to have an Indwelling Catheter in place. A brief interview was conducted with Resident #7 in which he stated that he has had the catheter for a long time. In addition, he acknowledged that the catheter is medically necessary because otherwise he would be in a lot of pain. Record review for Resident #7 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Urinary Tract Infection (UTI), Neuromuscular Dysfunction of Bladder, Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms. Review of the Nursing Progress notes revealed that on 03/25/2024…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure timeliness of physician visits for 1 of 29 sampled residents (Resident #32). The findings included: Review of the facility's policy titled, Physician Visits and Physician Delegation dated 05/01/2023 included in part the following: 2. The Physician should: b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law. h. At the option of the physician, required visits in SNFs (Skilled Nursing Facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnosis 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to adequately monitor behaviors for residents receiving psychotropic medications for 5 out of 81 residents receiving psychotropic medications (Resident #32, 34, 96, 5, 116). The findings included: Review of the facility's policy titled; Use of Psychotropic Medication dated 05/01/2023 included in part the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 3. The attending…

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 observations record review and interview; the facility failed to secure medications at bedside for 1 of 29 sampled residents (Resident #34). As evidenced by medication (eye drops) observed on the resident's nightstand. The findings included: Review of the facility's policy titled, Medication Storage dated 05/01/2023 included in part the following: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Record review for Resident #34 revealed the resident was admitted to the facility on [DATE] and readmitted 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, it was determined that the facility failed to provide food prepared in a pureed form designed to meet the needs of 2 sampled residents (Resident's #1, and #43) out of 12 facility residents with physician ordered pureed diet. The findings included: 1) During the observation of the breakfast meal in the Main Kitchen on 06/18/2024 at 7:30 AM it was noted that the pan of pureed eggs located in the steam table appeared to be lumpy and were not smooth in consistency. The surveyor requested the eggs to be taste tested by the facility's Registered Dietitian at the time of the observation and it was noted that the dietitian revealed the eggs were gritty in consistency and large pieces of eggs were not properly blundered into a smooth consistency. The Dietitian reported the eggs should not be served to residents with a physician ordered pureed diet. It was requested that the eggs not be served until proper pureed consistency was obtained. Interview with the breakfast…

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 interview, the facility failed to ensure the Discharge Minimum Data Set (MDS) assessment was submitted in a timely manner for one (Resident #95) out of one resident who was triggered for late MDS submissions. The MDS record was over 120 days old. There were 111 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's Assessment Frequency and Timeliness of the Minimum Data Service (MDS) Assessment Policy and Procedure (implemented [DATE], revised [DATE]) documented: Policy Statement: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI (Resident Assessment Instrument) Manual; Policy Explanation and Compliance Guidelines: 1) The MDS/RAI Coordinator will be responsible for tracking due dates for all MDS assessments; 6) A discharge assessment will be completed within 14 days of the discharge date . Closed record review of the Resident Assessment…

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 interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident #110) out of one resident reviewed for resident assessments. Resident #110 was coded as being discharged to the hospital, but the resident was discharged home. There were 111 residents residing in the facility at the time of the survey. The findings included: Closed record review of the Demographic Face Sheet for Resident #110 documented the resident was admitted on [DATE] with diagnoses that included paraplegia, hypertension, hyperlipidemia, insomnia and diabetes mellitus. The resident was discharged on 10/21/22. Review of the Discharge Return Not Anticipated MDS, dated [DATE] for Resident #110 documented: The discharge-return was not anticipated; It was a planned discharge; Discharge to acute hospital; discharge date was 10/21/22. The MDS was incorrect. The resident was discharged home and not to the hospital. Review of the Physician's Order Sheet dated October 2022 for Resident…

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 observations, records reviewed and interview the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR). Level I for Serious Mental Illness (SMI) or Intellectual Disability (ID) was accurately completed at the time of admission for one resident (Resident #32) out of one resident whose PASRR was reviewed. This deficient practice has the potential to affect 111 residents residing in the facility at the time of the survey. The findings included: Observation of Resident # 32 on 01/18/2023 at 09:23 AM. Resident was observed having breakfast seated on his bed. with several juice cans on the side table. Resident #32 reported that he did not drink juices that are not good for his health. On 01/19/2023 at 11:05 AM, Resident #32 was not in his room and was out on pass with his wife. Observation of Resident # 32 on 01/20/2023 at 12:07 PM, revealed the resident in bed with eyes closed and no distress noted. Review of Resident #32's admission record revealed the resident was admitted 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 record review, observations and interviews, the facility failed to implement a written care plan to ensure one (Resident #73) out of one resident reviewed for bowel and bladder incontinence received adequate incontinence care and ensure incontinent products were readily available for incontinence care. As evidence by Resident # 73 was left soiled for 3 hours by facility staff. 2) the facility failed to ensure care plan was implemented for the accurate provision of oxygen for two residents (Resident #514 and Resident #70) out of three residents reviewed for oxygen treatment. This has the potential to affect 14 residents receiving respiratory treatment. There were 111 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's Comprehensive Care Plans Policy and Procedure (implemented 11/28/2017, reviewed 7/07/2022) documented the following: Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan…

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 one (Resident #73) out of one resident reviewed for bowel and bladder incontinence received adequate incontinence care. Resident #73 did not receive incontinence care for over three hours. Incontinent products such as adult briefs were not readily available. The facility failed to ensure that residents requiring incontinent care had the needed supplies and were being checked and changed as needed in a timely manner based upon the resident's voiding pattern to meet professional standards of practice. This deficient practice has the potential to affect 73 residents receiving bowel incontinence care out of 111 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's Activities of Daily Living (ADL) Policy and Procedure (implemented 11/28/2017, reviewed 10/26/2022) documented the following: Policy Statement: The facility will ensure a resident's abilities in ADLs 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to 1) ensure one (Resident #514) out of three residents reviewed for oxygen treatment received continuous oxygen treatments and 2) one resident (Resident #70) received the correct amount of oxygen out of three residents reviewed for oxygen treatment. This has the potential to affect 14 residents receiving respiratory treatment out of 111 residents residing in the facility at the time of this survey. The findings included: 1) Record review of the Oxygen Administration Policy and Procedure (implemented 11/28/2017, reviewed 11/28/2020) documented the following: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the residents' goal and preferences. Policy Explanation and Compliance Guidelines: 1) Oxygen is administered under orders of a physician; 3) Staff shall document the initial and ongoing assessment of the resident's condition…

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, record review and interview the facility failed to maintain communication with hospice to ensure continuation of care for 1 (Resident #79) out of 2 residents receiving hospice care, as evidenced by no updated hospice communication notes available in Resident #79's medical records. There were 111 residents residing in the facility at the time of this survey. The Findings Included: During observation on 1/17/23 at 8:50 AM Resident #79 was observed in bed, Tube feeing was running at 70 milliliters per hour (ML per Hr.), flush orders 30 ML per hr., Oxygen concentrator and nebulizer in room. On 01/18/23 at 08:36 AM Resident #79 observed in bed asleep, call light on bed Tube Feeding running at correct rate, no distress noted. During observation on 01/19/23 at 10:08 AM Resident#79 in bed laying down, eyes open, no distress noted, Tube Feeding running at correct rate. Review of the medical records for Resident #79 revealed the most recent documentation from Hospice being on site for Resident #79…

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 demonstrate Quality Assurance and Performance Improvement (QAPI) implemented effective plan of actions to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 645- Preadmission Screening and Resident Review (PASRR) and F 656- Develop/Implement Comprehensive Care Plans. These repeated deficient practices have the potential to increase the risk of negative resident outcomes and to affect all 111 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 08/27/2021 the facility was cited F 645 due to the facility's failure to ensure completion of a level II - Preadmission Screening and Resident Review (PASRR) for two out of three residents. The facility was also cited F 656 for failure to Develop/Implement Comprehensive Care Plans related to pressure ulcers. During this survey with exit dated 1/20/2023 the facility was cited F 645 and F 656.…

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.