Beachside Post Acute

Inspectors wroteBased on observation, interview and record review the facility failed to ensure seven out of 10 sampled residents, (Resident 1, 10, 45, 52, 54, 55 and 67), who were not able to carry out Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) to maintain good grooming by:Failing to ensure Residents 1,10,45,52 and 54 fingernails were not long with jagged (sharp, uneven) edges. Failing to ensure Residents 55 and 67 who had long, jagged mycotic (fungus) toenails were seen by a podiatrist (foot doctor). These failures had the potential to cause pain, inflict injury and spread infection by not ensuring the fingernails for Resident's 1, 10, 45, 52 and 54 were kept short and free from jagged edges and by not ensuring Resident's 55 and 67 were seen by a podiatrist for their long, jagged mycotic toenails.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in a safe and sanitary manner. The facility had 69 residents receiving oral diet. The facility failed to:1. Ensure open bags of frozen pizza dough, corn, potato puffs and hotdogs were stored in an airtight container or bags. This failure had the potential to place residents at risk for developing food borne illnesses (any illness resulting from eating contaminated/spoiled foods) and could reduce the quality of food served in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices. The facility failed to:1. Ensure staff performed hand hygiene in between residents when passing lunch trays.2. Ensure Licensed Vocational Nurse (LVN) 1 performed hand hygiene before, and after medication administration on Resident 20.3. Observe Enhanced Barrier Precautions (EBP- infection control rules used in nursing homes to stop the spread of dangerous, hard-to-treat germs) before administering Resident 20's medication through gastrostomy tube (GT- a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 33 and Resident 88) were appropriately notified regarding the changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC-given by the facility to residents at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending) form. This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file and appeal.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) was notified for one of three sampled residents (Resident10) who was hospitalized on [DATE]. This failure violated the rights of Resident 10 by not notifying the ombudsman to ensure Resident 10's discharge was safe and appropriate.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 6) with a positive Preadmission Screening and Resident Review Level 1 screening ([PASRR] a federal requirement to identify individuals with serious mental illness ([SMI] a mental, behavioral, or emotional condition that interferes with or limits a person's ability to function in daily life ), and intellectual disability ([ID] when a person has significant limitations in their mental abilities), prior to admission to the facility received a required PASARR Level II evaluation to determine the need for specialized services and appropriate placement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care for one of ten sampled residents (Resident 20). The facility failed to:1. Ensure Licensed Vocational Nurse (LVN) 1 verified the placement of the gastrostomy tube (GT-a soft tube surgically inserted directly into the stomach to administer medications, fluids, and nutrition) and checked or assessed the gastric residual volume (GRV-the amount of fluid or tube feeding formula [liquid nutrition] remaining in the stomach at a specific point in time) of Resident 20's GT prior to administering medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were informed of and individualized, trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma for residents with Post-Traumatic Stress Disorder (PTSD a mental health condition that can develop after experiencing or witnessing a traumatic event) for two of three residents reviewed for PTSD (Residents 28 and 66). This failure resulted in staff not being aware of each resident's PTSD triggers and increased the risk of unnecessary stress or escalation for the residents.

Inspectors wroteBased on observation, interview and record review the facility's Social Services Director (SSD) failed to ensure two out of 10 sampled residents (Resident's 55 and 67) were seen by a podiatrist (foot doctor) for treatment of their long, jagged (sharp, uneven) mycotic (fungal) toenails. This deficient practice resulted in a delay in necessary care and services for Resident 55 and Resident 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications are administered safely and in accordance with accepted standards of practice on two of nine sampled residents (Resident 20 and Resident 50). The facility failed to:1. Ensure Licensed Vocational Nurse (LVN) 1 verified the placement of the gastrostomy tube (GT-a soft tube surgically inserted directly into the stomach to administer medications, fluids, and nutrition) and checked or assessed the gastric residual volume (GRV-the amount of fluid or tube feeding formula [liquid nutrition] remaining in the stomach at a specific point in time) of Resident 20's GT prior to administering medications. 2. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteb. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.