Beach Terrace Care Center

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure it maintained a comfortable and homelike environment with comfortable temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the resident rooms and areas. This was identified for 18 (Room G28, 124, 125, 127, 128, 133, 136, 201, 216, 219, 222, 225, 226, 228, 230, 232, 233, and 236) of the 83 resident rooms during the Environment Task. Specifically, 18 resident rooms and the first-floor shower room ambient temperature was measured to be below 71 degrees Fahrenheit. Multiple residents complained of being uncomfortable due to the cold room temperature. The finding is: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not maintain the heating system in proper working conditions to provide a healthy, functional, and comfortable environment for residents, personnel, and the public. This was identified for 19 (Room G28, 120, 124, 125, 133, 134, 136, 201, 216, 219, 222, 225, 226, 228, 230, 232, 233, and 236) of the 83 resident rooms during the Environment Task. Specifically, the heating system in multiple resident rooms did not function as intended to provide comfortable and safe environmental temperatures. Cross Reference-F584: Safe/Clean/Comfortable/Homelike Environment.

Inspectors wroteBased on record review and interviews, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's current status. This was identified for one (1) (Resident #72) of two (2) residents reviewed for Dialysis. Specifically, 1) Resident #72 receives dialysis three times a week which was not identified in the Minimum Data Set assessment dated [DATE]. The finding is:The undated facility policy titled, MDS (Minimum Data Set) 3.0 documented that every department will be responsible for accurate completion of the assigned Minimum Data Set sections. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that each resident who needs respiratory care is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified as one (1) (Resident #63) of four (4) residents reviewed for Oxygen administration. Specifically, Resident #63 had a physician order to receive supplemental oxygen therapy via a nasal cannula. During an observation on 01/21/2026, the resident was not utilizing the supplemental oxygen therapy and the oxygen tubing, and an oxygen mask was laying on top of an oxygen concentrator (a machine that delivers purified oxygen) adjacent to Resident #63's bed (not in use). There was no nasal cannula present at the resident's bedside. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure that its Facility Assessment considered specific staffing needs for each resident unit and each shift, such as day, evening, night, in the facility and adjusted as necessary based on changes to its resident population. This was identified during the Sufficient and Competent Staffing task. Specifically, the Facility assessment dated [DATE] did not document the number of nursing personnel needed to meet resident needs for each unit for each shift. The finding is:The facility policy titled Annual Facility assessment dated 01/2024 documented it is the policy of the facility to conduct and document a facility-wide assessment to determine the resources necessary to care for our residents competently during both day-to-day operations and emergencies to ensure that quality care and quality of life are maintained. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00383402), the facility did not ensure that residents representative, for one of three residents reviewed for notification (Resident #1), who was designated as the emergency contact person was notified, provided education and given an opportunity to consent or decline prior to performing a treatment change/medical procedure. Specifically, Resident #1 was stated on intravenous antibiotic and Family Member#1 was not notified, additionally Resident #1 developed a facility acquired wound to left toe and Family Member #1 was not notified.

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for five of the five units reviewed for the Sufficient Nursing Staffing task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter 1, 2024 indicated excessively low weekend staffing and 2) a review of the daily staffing sheets revealed that the facility did not provide sufficient numbers of Certified Nursing Assistants as indicated in the facility assessment. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024 the facility did not ensure that all alleged violations, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in a serious bodily injury, to the New York State Department of Health. This was identified for one (Resident #48) of three residents reviewed for skin conditions and one (Resident #83) of seven residents reviewed for Accidents. Specifically, 1) Resident #48 sustained a scrotal avulsion (a forcible tearing off the skin of the scrotum) on 1/25/2024 requiring surgical intervention. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024 the facility did not ensure that each allegation of abuse, neglect, exploitation, mistreatment, or injury of unknown origin was thoroughly investigated. This was identified for one (Resident #48) of three residents reviewed for skin conditions and one (Resident #83) of seven residents reviewed for Accidents. Specifically, 1) Resident #48 sustained a scrotal avulsion (a forcible tearing off the skin of the scrotum) that required surgical intervention on 1/25/2024. The cause of the injury was unknown. There was no investigation to determine the root cause of the injury. 2) Resident #83 sustained a discoloration to the right eye and right forehead on 6/22/2024. Resident #83's injury was of unknown origin. [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure the comprehensive care plan was reviewed and revised to meet each resident's current needs. This was identified for one (Resident #62) of two residents reviewed for Environment. Specifically, Resident #62, who resided on the second floor of the facility, had behaviors of stuffing the toilet with objects that clogged the toilet resulting in a leaked ceiling in other residents' rooms residing on the first floor. A comprehensive care plan was developed for the resident's behavior in 2014 with interventions to manage the resident's behavior. The resident continued to exhibit the behavior; however, the interventions on the comprehensive care plan remained unchanged since 2014. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for two (Resident # 107 and Resident #138) of five residents reviewed for Pressure Ulcers. Specifically, Resident #107 and Resident #138 had a physician's order for an alternating pressure relief air mattress. During multiple observations, the adjustable weight setting on the air mattress pump was not accurately set according to each resident's weight.

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (Resident #113) of two residents reviewed for Respiratory Care. Specifically, Resident #113 had a physician's order to receive 3 liters of oxygen per minute every shift. The resident was observed receiving 4.5 liters of oxygen per minute on 6/27/20224 and 6/28/2024 and 5 liters of oxygen per minute on 7/1/2024. The finding is: The facility's policy and procedure titled Oxygen Concentrator last revised in March 2017, documented that while delivering oxygen via an oxygen concentrator, the flow meter knob is to be adjusted to the ordered flow rate. [...]

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure the medical care of each resident is supervised by a Physician. This was identified for one (Resident #113) of two residents reviewed for Respiratory Care. Specifically, Resident #113 had a physician's order for supplemental oxygen therapy at 3 liters per minute every shift; there was no rationale documented for the use of supplemental oxygen. Additionally, the resident expressed that the oxygen therapy has not been effective. There was no documented evidence in the resident's medical record that the Physician monitored and evaluated the resident's oxygen therapy needs until after the Surveyor brought the concern to the facility's attention on 7/2/2024. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on two (Unit 2 East and Unit 2 West) of three units reviewed during the Medication Storage Task. Specifically, 1) a used vial (bottle) of insulin for Resident #86 was observed in the medication refrigerator, on Unit 2 East on 7/2/2024, with an open date of 5/29/2024; 2) two opened bottles of Latanoprost Ophthalmic Solution for Resident #76 and Resident #109 were observed in the medication cart on Unit 2 [NAME] on 7/2/2024 without a date that indicated when the eye drop bottles were opened; [...]

Inspectors wroteBased on observation, record review, and interviews during abbreviated survey (NY00326327), the facility did not ensure that an incident of a resident-to-resident altercation was reported immediately, but not later than 2 hours if there were serious bodily injuries or not later than 24 hours if there were no serious bodily injuries. This was identified for one (Resident #1) of 3 residents reviewed for Abuse. Specifically, on 10/12/2023 Resident #1 reported to the nursing staff that Resident #2 yelled and hit them multiple times. The facility did not report the resident-to-resident altercation incident to the New York State Department of Health (NYSDOH).

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey initiated on 10/11/2022 and completed on 10/18/2022, the facility did not ensure that pain management was provided for each resident who requires such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for four (Residents #39, #40, #121 and #79) of four residents reviewed for pain management. Specifically, the facility did not consistently assess residents for pain and did not monitor the effectiveness of pain medication.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 10/11/2022 and completed on 10/18/2022, the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for one (Resident #81) of four residents reviewed for pressure ulcers. Specifically, Resident #81 was identified with a small opening on the sacrum on 7/14/2022; however, the wound was not assessed until 7/19/2022, five days after the wound was first identified. On 7/19/2022 the wound care Nurse Practitioner (NP) assessed the wound as an unstageable pressure ulcer. The finding is: [...]