North Beach Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are properly stored, accurately accounted and dispensed in accordance with professional standards as evidenced by: Packages with medications for return to pharmacy left unattended at the Nurses stations; medication and treatments carts left unattended and unlocked. Discrepancies identified on the Controlled Drugs Disposition Records for South Wing Cart two. Discontinued medication observed on North Wing Medication Cart One. Date discrepancies for Ophthalmic treatments on Medication Carts. Medications left unattended during medication administration observation for Resident # 15 and sharing medications between residents intercepted by surveyor. There were 94 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review the facility 1) failed to have available disposable towels at the hand washing sink in the kitchen for the dietary staff, 2) failed to ensure food is being stored under sanitary condition and resident's food items were dated and labeled in the freezer and outdated food was discarded in a timely manner and 3) failed to ensure the hydration cart containing an ice cooler and ice scoop were handled in a sanitary manner to prevent contamination. This has the potential to affect 88 out of 94 residents who eat orally residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate effective plans of action were implemented to identify and correct quality deficiencies related to repeated deficient practices under F761-Labeling/Storage of Drugs and Biologicals. As evidenced by the facility failed to ensure medications and medication carts were properly secured and stored to prevent unauthorized access. There were 94 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to accommodate one (Resident #51) out of one resident's choice for food preferences reviewed. There were a total of 94 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to secure confidential information for residents on two (South and North) out of two units as evidenced by: 1) Residents' medical information left visible and unattended at the front desk. 2) Residents' personal information visible and unattended on the North unit. 3) Residents' medical information posted on the wall of the South unit. 4) Paperwork with residents' information visible and unattended at the North unit nursing station. 4) An open computer screen with residents' medical information visible and unattended on the South unit medication cart #2. 5) An open computer screen and 2 binders with residents' medical information were left visible and unattended on the South unit nursing station. There were 94 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed provide needed care and services for one (Resident #89) out of two sampled residents, who had diabetic ulcer as evidenced by observations of Resident #89 in bed with heels lying flat on the bed. There were two residents with diabetic ulcers residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' environment remained free of accident hazards on one (North unit) out of two units as evidenced by: 1) The facility's staff failed to lock a housekeeping cart containing hazardous chemicals. 2) The facility's staff failed to keep a closet door that locks on the inside and contained wound care supplies remained locked. There were 3 housekeeping carts in the facility at the time of survey and 94 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record reviews, the facility's staff failed to position an indwelling urinary catheter tubing in accordance with professional standards of care for two (Resident#1 and Resident#62) out of two sampled residents, who had an indwelling urinary catheter as evidenced by: 1. The facility's staff positioned Resident#1's indwelling urinary catheter tubing in a manner causing back flow of urine and 2. The facility's staff positioned Resident#62's suprapubic urinary catheter tubing in a manner causing back flow of urine. This increased the risk of catheter-associated urinary tract infections and other serious medical issues. There were four residents with indwelling catheters and one resident with a suprapubic catheter residing in the facility at the time of survey. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure staffing information on the North Wing and South Wing were readily available in a readable format to residents and visitors at any given time.

Inspectors wroteBased on observations, record review, and interviews the facility failed to provide a safe environment for all residents, as evidenced by one out of three dryer lint traps in the laundry room observed full of lint. There were 94 residents residing in the facility at the time of survey.

Inspectors wroteBased on record review and interviews facility failed to notify the Office of the Ombudsman about the transfer of five residents (#17, #16 #10, #24, #73) out of 23 residents sampled, as evidenced by reports of unsuccessful fax transmittals for The Notice of Transfer/Discharge Letter to The Office of The Ombudsman for December and November 2024. There were 94 residents residing in the facility at the time of survey.

Inspectors wroteObservation on 01/06/25 at 09:32 AM Resident #9 was in bed with eyes closed, a medicine cup with a small pink pill was noted on the bed next to Resident #9 (photo evidence). Resident #9's nightstand drawer was open, and a bottle labeled Vitamin C was observed inside (see photo evidence). On 01/06/25 at approximately 9:38 AM, Staff A, Licensed Practical Nurse (LPN) stated: I did not give [Resident#9] any medication. No medications can be kept in the residents' rooms without staff present. Staff A, LPN entered the resident's room with the surveyor and removed cup with the pink pill and disposed of it in the puncture resistant container in the medication cart. Staff A, LPN returned with the Director of Nursing (DON) and the DON removed the bottle labeled Vitamin C and educated Resident #9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food under sanitary condition by ensuring 1) the resident's foods were dated, the refrigerator was working properly and 2) there was no thermometer in the refrigerator in the snack/nourishment refrigerator on the resident's unit. This has the potential to affect 89 out of 94 residents who eat orally residing in the facility at the time of the survey and the potential to affect 55 out of 57 residents who eat orally residing on the North Wing and affect 34 out of 36 residents who eat orally residing on the South Wing.

Inspectors wroteBased on observations, record review, and interviews the facility failed to follow infection prevention and control practices with one out of two vital signs machines in the facility and one out of three dryer lint traps in the laundry room, as evidenced by staff member not disinfecting the vital signs machine after measuring a resident's blood pressure and Clean laundry (curtains) stored in washing area.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident # 398) out of three sampled residents devices was in place to alert staff in the event of an emergency as evidence by Resident 398's call light and phone were observed out of the resident's reach.

Inspectors wroteBased on interviews and record review facility failed to implement a nutritional care plan for one resident out of seven residents sampled (Resident #297) as evidenced by staff failed to notify the physician about an incident of aspiration reported by an alert and oriented resident. There were 94 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide quality of care for two residents (Resident #297 and Resident #398) out of twenty-three sampled residents, as evidenced by a Licensed Practical Nurse (LPN) failed to notify the physician and document an incident of food aspiration reported by Resident #297 and failure to position Resident# 398 appropriately during meals to prevent aspiration. There were 94 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record reviews facility failed to provide adequate supervision to ensure an environment free of safety hazards for two residents (#9, #17) out of 23 sampled residents as evidenced by boxes of cigarettes and electrical cigarette at Resident #9's bedside and a shaving razor at Resident #17's bedside. There were 94 residents residing in the facility at the time of survey.

Inspectors wroteBased on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F558 Reasonable Accommodations Needs/Preferences, F761 Label/Store Drugs and Biologicals, F880 Infection Prevention & Control, These deficient practices have the potential to affect 94 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interviews and record review, the facility failed to protect one (Resident #1) out of three residents sampled during the time of this survey. The facility's staff (Staff A Licensed Practical Nurse (LPN), Staff C LPN and Staff D, Certified Nursing Assistant) failed to supervise and implement adequate measure to prevent the elopement of Resident #1 who was exit seeking, wandered the unit, and wandered near exit doors. The facility neglected to adequately monitor and address Resident #1's displayed exit seeking behaviors and intent of elopement. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system was in place allowed the resident to elope undetected by staff on 1/19/2024 at 1:34 AM on foot and the facility's staff did not begin the search until 2:50 AM and did not find the resident. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staffs' failure implement the facility's policy related to wandering and elopement and failed to provide care and services including adequate supervision for one (Resident #1) out of three residents sampled. This deficient practice enabled Resident #1 to exit the facility at 1:34 AM on 01/19/2024, undetected. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate and effective alert monitoring system was in place, allowed the resident to elope undetected. The resident has not been located as of 02/01/2024.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of three sampled residents with exit seeking behaviors. This deficient practice enabled Resident #1 to exit the facility at 1:34 AM on 01/19/2024, undetected. The facility's system failure, lack of adequate supervision and failure in ensuring an adequate and effective alert monitoring system was in place, allowed the resident to elope undetected. The resident has not been located as of 02/01/2024.

Inspectors wroteBased on record reviews,observations and interviews the facility's administration failed to implement, provide, and ensure effective and efficient preventative measures were in place to prevent the neglect and elopement of one resident (Resident #1) out of three sampled residents who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure exit door alarm was audible in all areas of the facility in the event of an emergency and failure by staff to implement assigned level of supervision for resident #1 who had exit seeking behaviors, wandered the unit and wandered near exit doors and had the potential for elopement. [...]

Inspectors wroteBased on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice. The facility's history includes deficient practice for failing to supervise residents resulting in elopement within the past 10 months. The previous incident resulted in the identification of immediate jeopardy that occurred when another resident eloped from the facility undetected on 3/19/2023 and was found deceased . The facility had surveys with IJ levels citations in the previous three years during surveys. The facility was cited for Free of Accident Hazards, Supervision, Devices, Administration and Quality Assurance and Assessment. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain an accurate record for one (Resident #1) out of three residents reviewed for elopement. The resident had a doctor's order to wear an alarm bracelet and it was documented the resident wore the alarm bracelet every day on each shift, but the resident was not wearing said alrm bracelt as documented in the medical record.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to obtain physician's order for oxygen therapy for five (#2, #46, #87, #192, and #242) residents out of fourteen residents who were receiving oxygen treatment.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to treat with respect and dignity two out of two residents (Residents #68 and #79) who was observed during dining, as evidenced by failure to staff member standing while feeding the resident. This deficient practice had a potential to affect the health and wellbeing of all 28 residents who were dependent with eating.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure reasonable accommodations of residents' need for 5 (Residents #15, #48, #59, #63 & #392) out of 6 sampled residents, as evidenced by call lights were not within reach for the residents and a residents room light did not turn off. This facility's deficient practice had the potential to affect any of the 95 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I for mental illness (MD) or intellectual disability (ID) was completed at the time of admission for resident one (Resident # 59) out of one residents investigated for PASARR. This deficiency had the potential to affect 95 residents residing in the facility at the time of the survey.

Inspectors wroteBased on interview and record review, the facility failed to develop a smoking and oxygen care plan for resident # 12 and #192 out of 14 sampled residents reviewed at the time of the survey for oxygen and smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have daily nurse staffing posted prior to the beginning of shifts on 2 of 2 nurses' stations. This had the potential to affect the 95 residents who resided in those units at the time of this survey.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the accuracy of narcotic records on two out of four medication carts reviewed. There were 95 residents residing at the facility at the time of the survey.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensured medications were securely stored as evidenced by one loose medication pill found on the floor of a resident's room and loose pills found on two out of four carts checked. There were 95 residents residing in the facility at the time of the survey.

Inspectors wroteBased on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F695 Respiratory/tracheotomy Care and Suctioning and F880 Infection Prevention and Control. This practice has the potential to increase the risk of negative resident outcomes and to affect all 95 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure infection control practices related to hand hygiene was implemented during dining observation. As evidenced by staff failure to sanitize hands while passing resident meal trays. This deficient practice has the potential to cause cross contamination and affect all residents in the facility. There were 95 residents residing in the facility at the time of this survey. The indings included: Observation on 08/28/23 at 12:08 PM Staff F, Certified Nursing Assistant (CNA), brought 3 food trays to room [ROOM NUMBER], then Staff F set up the plates for the residents. Observed Staff F come out of the room, not washing her hands, and picked up some linens on a cart. Observed Staff F left with the linens and came back to the food cart. [...]