Palm Beach Nursing Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services in a manner to provide a clean and sanitary environment in 20 of 62 rooms and in the common areas of the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to prepare, store and serve food in a sanitary manner in accordance with standards for food safety professionals.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to address equipment repair of a malfunctioning bed in a timely manner for 1 of 22 sampled residents, failed to maintain a call light within reach for 1 of 22 sampled residents, and failed to maintain residents' items in an accessible manner for 1 of 22 sampled residents, Resident #3, Resident #46, and Resident #131.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess residents accurately and in a timely manner for a change in status for 1 of 1 sampled resident, Resident #5.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely administer PRN (as needed) pain medication to a resident with voiced pain for 1 of 1 sampled resident, reviewed for pain management, Resident #139.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately document the narcotic medication dispended, administered or disposed of for 3 of 4 sampled residents reviewed for Narcotic Medication Storage, Residents #25, #33 and #58.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately label and store drugs in accordance with currently accepted professional principles for 1 of 3 sampled residents for medication administration observation, Resident #16.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the approved recipe for the desserts that were served for lunch on 01/06/26 and 01/07/26.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that avoids allergens for 1 of 6 sampled residents, Residents #103, and the facility failed to provide food according to residents' preferences for 1 of 6 sampled residents, Residents #3.

Inspectors wroteBased on record reviews and interviews the facility failed to coordinate the care ordered by the podiatrist for 1 of 3 sampled residents (Resident #2).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure right to privacy for Resident's person and records affecting Resident #9, #116, and #77, related to privacy curtains, loudly speaking residents's diagnosis, walking into resident rooms without permission and leaving residents naked.

Inspectors wroteBased on observations, interviews, and staffing calculations, the facility failed to ensure sufficient staffing as evidenced by identified care issues during this survey, voiced concerns from Residents #73, #31, #74, #63, #45, #221, and #104, documented low-weekend staffing, and concerns voiced in Resident Council.

Inspectors wroteBased on observation and interviews, the facility failed to ensure a clean, comfortable and homelike environment for residents on 3 of 4 units.

Inspectors wroteBased on policy review, observation, record review, and interview, the facility failed to respond to a voiced complaint for 1 of 1 sampled resident. Resident #38 voiced a concern about her roommate to staff with no further action or response taken.

Inspectors wroteBased on record review and interviews, the facility failed to ensure timely, accurate, and complete Preadmission Screening and Resident Record Review (PASSARs) for 3 of 4 sampled residents reviewed for PASARR's (Residents #64, #78, and #94).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activity of daily living (ADL) care for 3 of 7 sampled residents related to incontinence for Resident #45, hair shampoo and incontinence care for Resident #74, and nail care for Resident #8.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders related to blood pressure parameters and failed to obtain blood pressure and heart rate vital signs for 2 of 5 sampled residents reviewed for medication usage (Residents #40 and #73), and failed to ensure the provision of medications for 1 of 1 sampled resident who voiced complaints (Resident #82).

Inspectors wroteBased on record review, observation, interview and policy review, the Facility failed to timely provide the prescribed eyeglasses for 1 of 2 residents sampled for vision (Resident #35).

Inspectors wroteBased on policy review, record review, observation, and interview, the facility failed to ensure proper incontinence care for 1 of 4 sampled residents reviewed with a history of Urinary Tract Infections (UTIs) (Resident #66).

Inspectors wroteBased on policy review, record review, observation, and interview, the facility failed to ensure oxygen care and services for 4 of 5 sampled residents (Residents #78, #51, #31, and #82).

Inspectors wroteBased on observation, interview and record review, the medication error rate was 7.69 percent. Two medication errors were identified while observing a total of 27 opportunities, affecting 2 of 6 residents observed (Residents #64, and #57).

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory services for 2 of 5 sampled residents as evidenced by the failure to obtain a urine sample from Resident #66 three times as per physician order, and failure to obtain the most recent blood work for Resident #73.

Inspectors wroteBased on interviews, record reviews, and a review of the grievance logs, the facility failed to ensure that residents were served food at a palatable temperature for 3 of 15 sampled residents with voiced food concerns (Residents #82, #89, and #77), and 4 residents from Resident Council who voiced food concerns also (Residents #88, #84, #14, and #15).

Inspectors wroteBased on interviews and record reviews the facility failed to provide foods per preferences for 5 of 15 sampled residents with voiced food concerns (Residents #104, #63, #77, #73, and #107).

Inspectors wroteBased on policy review, record review, observation, and interview, the facility failed to follow Infection control practices during a blood sugar check for 1 of 2 sampled residents observed as evidenced by the failure to properly disinfection the glucometer (machine used to obtain the blood sugar level from a blood sample) (Resident #4), and failed to properly utilize personal protective equipment (PPE) for 1 of 2 sampled residents observed on Enhanced Barrier Precautions (EBP) (Resident #31).

Inspectors wroteBased on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 2 of 2 residential living areas (First and Second Floors) .

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician prescribed fluid restrictions for 3 (Resident #133, #119, and #276) of 3 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident to resident misappropriation of funds/property in a timely manner for 1 of 1 sampled residents reviewed for abuse (Resident #11).

Inspectors wroteBased on interview and record review, the facility failed to take corrective actions addressing misappropriation of a resident's funds/property in a timely manner for 1 of 1 sampled residents reviewed for abuse (Resident #11).

Inspectors wroteBased on observation, interview and record review, that the facility failed to provide services that included Speech Therapy, Dietary Services, Social Services, and Dental Services to ensure that 1 (Resident #122) of 9 sampled residents reviewed for nutrition maintained their ability to self feed independently.

Inspectors wroteBased on interview and record review, the facility failed to acquire lab results prior to administering an anticoagulant (blood thinner) to 1 of 5 sampled residents reviewed for unnecessary medications (Resident #24).

Inspectors wroteBased on record review and interview, the facility failed to respond to a urine culture results in a timely manner for 1 of 1 sampled residents reviewed for Urinary Tract Infection (UTI) (Resident #24).

Inspectors wroteBased on interview, observation and record review, the facility failed to accurately document controlled mediations for 3 of 5 residents (Resident #41, Resident #115, and Resident #132). The findings Included: The facility's policy and procedure titled, 7.0 Best Practices for Medication Dispensing: Scheduled II Narcotics has a subsection H. Dispensing of Controlled Dangerous Substances (CDS). The subsection has a numbered list of entries. Entry #5 states When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the inventory sheet the date of administration, the quantity administered, the amount of medication remaining, and his/her initials. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rates were not 5% or greater. The facility had a medication error rate of 13.79%. Four (4) medication errors were identified while observing a total of 29 opportunities, affecting Resident #21.