Indian Beach Nursing and Rehab Center

Inspectors wroteBased on interview, record review and facility policy the facility failed to protect the residents' rights to be free from misappropriation of residents' property for 6 (Residents #1, #2, #3, #4, #5 and #6) of 6 residents reviewed out of 51residents whose personal funds are managed by the facility.

Inspectors wroteBased on record review, review of the facility's policies and procedures, residents and staff interviews, the facility administration failed to utilize its resources effectively and provide the necessary oversight to prevent the misappropriation of residents' personal funds for 6 (Residents #1, #2, #3, #4, #5 and #6) of 6 of 51 residents whose funds are managed by the facility.

Inspectors wroteBased on record review, review of facility policy and procedure and staff interview, the facility failed to report an allegation of misappropriation of resident property within required timeframe for 1 of 3 incidents reviewed.

Inspectors wroteBased on record review, review of the facility's policy and procedure, residents and staff interviews, the facility failed to thoroughly investigate an allegation of misappropriation of residents' property for 1 of 1 incident investigation related to misappropriation of residents' personal funds reviewed.

Inspectors wroteBased on record review and facility staff interview, the facility failed to protect residents' rights to personal privacy for 2 (Residents #16 and #7) of 2 residents observed in unauthorized videos posted on staff personal social media account accessible to the public.

Inspectors wroteThe immediate actions implemented by the facility and verified by the survey team on 5/24/25 included: On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees. On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms. On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. [...]

Inspectors wroteThe immediate actions implemented by the facility and verified by the survey team on 5/24/25 included: On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees. On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms. On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. [...]

Inspectors wroteThe immediate actions implemented by the facility and verified by the survey team on 5/24/25 included: On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees. On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms. On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change in status assessment for 1 (Resident #17) of 1 sampled resident with a 9.41% weight loss over a six month period and developed an unstageable pressure ulcer.

Inspectors wroteBased on observation, record review, residents and staff interviews, the facility failed to ensure timely repairs to maintain a safe and comfortable environment for 8 (Residents #1, #2, #6, #19, #20, #21, #22, and #23) of 15 residents of the [NAME] wing (300 hall).

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to demonstrate prompt efforts to address and resolve grievances related to comfortable temperature, pest control and staff treatment of residents for 10 (Residents #1, #2, #7, #6, #5, #8, #9, #10, #11 and #13) of 10 sampled residents who complained about unresolved grievances.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to implement effective pest control measures to address ongoing sightings of roaches.

Inspectors wroteBased on observation, resident, staff interviews, and records review, the facility failed to ensure 1 (Resident #16) of 1 resident reviewed had clothing in good condition.

Inspectors wroteBased on record review, resident interview, and staff interviews, the facility failed to implement their policy and have documentation of prompt efforts to resolve a grievance for 1 (Resident #45) of 2 residents reviewed for unresolved grievances.

Inspectors wroteBased on observation, staff interview and record review the facility failed to revise and/or update the plan of care for 1 Resident (#24) of 1 resident with exit-seeking behaviors.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled drugs (narcotic) count records where complete for 2 (Split Hall and [NAME] Hall) of 2 controlled drugs records reviewed.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe, sanitary, comfortable and home like environment for residents by not having clean surfaces; resident room furniture and common areas in disrepair; not repairing damaged walls in resident rooms and bathrooms; and having thread bare/torn linens in resident rooms. Not maintaining a sanitary environment had the potential to cause infections and cross contamination and bio growth.

Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to report resident-to-resident abuse to the appropriate state agency for 2 of 2 reports reviewed. Failure to report had a potential for further incidents of abuse to occur to vulnerable residents.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a resident's care plan to address the identified problem of physical aggression resulting in injury towards another resident. The facility did not identify triggers, plan care, and provide individualized interventions to prevent and minimize agitation towards others for 1 (Resident #75) of 5 residents reviewed for behaviors.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to provide activities to meet the interests of 3 (Resident #7, #14, and #67) of 4 residents reviewed for activities. The lack of an ongoing activity program and lack of contact and interaction with the community could lead to a decline in residents' mental and psychosocial well-being.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility failed to administer prescribed and available medication to prevent 1 (Resident #76) of 1 resident reviewed from itching his skin causing multiple areas scratched to have broken and bleeding skin on his forearms, legs, and trunk. Resident did not receive his ordered medication for 8 days after it arrived, even though staff knew about the resident's skin condition.

Inspectors wroteBased on record review, staff and pharmacist interview, the facility failed to ensure timely administration of physician-ordered medications received from the pharmacy and/or available in the facility's emergency drug kit (EDK) to meet the needs of 2 (Residents #75 and #76) of 7 reviewed for medications. This resulted in Resident #76 not receiving ordered medications, causing to resident to scratch and itch to the point of breaking his skin and causing bleeding in several areas of forearms.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to maintain complete and accurate records in the areas of Activities of Daily Living (ADL), resident weights, and wound and treatments for 4 (Residents #15, #28, #65, and #76) of 18 residents reviewed. Accurate and complete records were necessary to document the course of a resident's care provided by the facility.