Richmond Beach Rehab

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse for 1 of 5 residents (Resident 1), reviewed for abuse reporting. The failure to report an allegation of sexual abuse to the State Agency placed the residents at risk for repeated incidents and unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure chlorine test strips (used to measure the concentration of free available chlorine in sanitizing solutions) were not expired in accordance with professional standards for 1 of 1 kitchen, reviewed for dinnerware sanitization and storage. This failure placed the residents at risk for unsanitary dining conditions and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a system that ensured the right to file grievances anonymously for 5 of 8 residents (Resident 26, 37, 10, 100 & 104), reviewed for grievances. This failure placed the residents at risk for unresolved concerns, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use, administer CPAP as ordered, and monitor oxygen (O2) saturation (the amount of oxygen in the blood) for 3 of 6 residents (Resident 52, 2 &104), reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to document medication administration in accordance with professional standards for 4 of 6 residents (Residents 46, 90, 29 & 93), reviewed for medication administration. This failure placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed by 4 of 12 staff (Staff W, K, O & P) and for 2 of 2 residents (Residents 29 & 44), reviewed for infection control. The failure to properly transport clean clothes, use Personal Protective Equipment (PPE-face shield/goggles, gowns) before entering a droplet precaution (measure taken to prevent spread of germs transmitted when a person coughs, sneezes, talks or breaths) room and during wound care, disinfect a glucometer (a device used to measure blood sugar level) and pen injector (device used to inject Liraglutide [medication that helps regulate blood sugar levels]), and ensure a urine-filled urinal was not placed next to a resident's meal tray, placed the residents, visitors, and staff at risk for infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent explaining the risks/benefits for psychotropic medication (alters mood, perception, and behavior) was completed prior to medication administration for 1 of 5 residents (Resident 12), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications prior to administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were evaluated and assessed, and/or a physician order was obtained for safe administration of medication for 2 of 3 residents (Residents 92 & 64), reviewed for self-administration of medication. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided during dining observations for 2 of 10 residents (Residents 89 & 47), reviewed for dining. The failure to ensure licensed nurses refrained from administration of medications during resident meals placed the residents at risk for a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 6 residents (Resident 107), reviewed for significant change in condition. The failure to complete an SCSA timely placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 3 of 24 residents (Residents 68, 13 & 8), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessments were completed accurately on the MDS regarding dialysis (treatment that helps body remove extra fluid and waste products from blood when the kidneys cannot), medication, and smoking placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR or PASRR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was followed up on or sent out for a Level II PASARR referral for 2 of 6 residents (Residents 15 & 12), reviewed for PASARR Screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were revised accurately to reflect changes related to discontinuation of medications for 2 of 22 residents (Residents 13 & 12), reviewed for care planning. This failure placed residents at risk for unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) was up to date for 1 of 5 residents (Resident 3), reviewed for pneumococcal immunizations. This failure placed the resident at risk for acquiring, transmitting, and/or experiencing potential complications from pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure the necessary treatment and services for pressure ulcer/pressure injury (PU/PI - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) was provided consistent with professional standards of practice for 1 of 1 resident (Resident 1), reviewed for pressure ulcer care. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 5 of 6 residents (Residents 41, 67, 36, 46 & 20), reviewed for PASARR Screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift for 6 of 7 days (11/23/2024, 11/24/2024, 11/25/2024,11/26/2024,11/27/2024 & 11/28/2024), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and/or biologicals were properly labeled, stored, and/or expired supplies were removed/discarded in accordance with current accepted professional standards for 2 of 4 medication carts (Cascade and Olympic Medication Cart) and for 2 of 2 medication room refrigerators (Cascade and [NAME] Medication Room Refrigerators), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications and medical supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin (hormone that lowers blood sugar level) pens were properly disinfected and hand hygiene practices were followed during medication administration for Resident 155, and failed to properly store personal care items for room [ROOM NUMBER] and Personal Protective Equipment (PPE) for 5 of 7 isolation carts in (Rooms 200, 215, 205, 118 & 325), reviewed for infection control. In addition, the facility failed to provide hand hygiene supplies for 2 of 2 medication rooms (Cascade & Baker), and failed to ensure disinfection of shared transfer lift equipment was conducted between resident use for 2 of 2 residents (Residents 82 & 301). These failures placed the residents and staff at an increased risk for infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to properly notify the Office of the State Long Term Care (LTC) Ombudsman (an advocacy group for residents) in writing, describing the reason for transfer for 1 of 1 resident (Resident 36), reviewed for hospitalization. This failure placed the resident at risk for not having the access to an advocate who informed residents about options and resident rights.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 19 residents (Residents 68), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding capturing occurrences during the look-back period for oxygen placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop baseline care plans and/or provide a written summary of the baseline care plan to the residents and/or their representatives for 2 of 2 residents (Residents 40 & 151), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing were appropriately stored for 2 of 3 residents (Residents 17 & 46), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream) care was consistently evaluated after treatments according to professional standards for 1 of 1 resident (Residents 70), reviewed for dialysis. This failure placed resident at risk for unmet care needs, and deterioration of chronic condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe transportation was provided for 1 of 3 residents (Resident 45), reviewed for transportation to an appointment in the facility van. This failure caused harm when the wheelchair tipped over causing ongoing pain in Resident 45's left shoulder, arm, and hand. The failure to ensure the straps attached to the floor of the van were securely attached to the wheelchair before/after appointment transportation placed other residents at risk for injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care of face mask and nasal tubing used for nebulizer machine (breathing treatment) and/or Continuous Positive Airway Pressure (CPAP - a breathing therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) were stored properly for 2 of 2 residents (Residents 35 & 91) reviewed for respiratory care. This failure placed the residents at for unmet care needs, respiratory infections, and related complications.