Sands at South Beach Care Center, the

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide food at an appropriate temperature per resident's request for Resident (#104) out of 37 sampled residents. There were 186 residents residing at the facility at the time of the survey. During the initial screening observation on 07/21/2025 at 9:26 AM Resident #104 was in the hallway in a wheelchair, no distress noted, stated the food here is not so good, the food is cold by the time I get around to eating it, When I asked the staff, particularly the Certified Nursing Assistants to heat my food up, they always say we are too busy to eat your food up and the microwave is too far away in the recreation room. Receiving cold food is a daily occurrence, especially breakfast, the eggs are always cold. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy of delivered mail for one resident (Resident #1) out of three residents that receive personal mail. As evidenced by mail addressed to Resident #1 was opened without his consent. This has the potential to affect 176 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observations, interviews and record reviews facility failed to keep residents' information confidential on the second floor, as evidenced by observations of open unattended computer screens with residents' information on the facility's back medication cart and Station II nursing station desk. There were 79 residents residing on the second floor at the time of the survey.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to implement a nutritional care plan for one (Resident #4) out of three sampled residents who receive enteral feedings, as evidenced by an observation revealed Resident #4 receiving Glucerna 1.2 calorie feeding despite a Nutritional Care Plan with an intervention to provide tube feeding and water flushes as ordered: Jevity 1.5 calorie. There were 18 residents receiving enteral feedings in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide a safe environment for residents as evidenced by four employee bathrooms not specifically labeled and locked when not occupied. There were 172 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure six out of thirty-four sampled residents were treated with dignity; as evidenced by staff did not knock on doors and failed to request permission before entering the residents' rooms (Residents #475, #476, #477 and #478) and staff were observed standing over residents while assisting them to eat (Resident #54 and Resident #98). There were 172 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment for four (Resident #75, Resident #83, Resident #138, Resident #150) out of four residents reviewed for resident assessments were accurately coded. There were 171 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents assessments were coordinated with the pre-admission screening and resident review (PASRR) program for four (Resident #75, Resident #83, Resident #138, Resident #150) out of seven residents reviewed. There were 171 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident received an accurate Preadmission Screening and Resident Review (PASRR) Level I screening for one (Resident #13) of seven residents reviewed. There were 171 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure controlled medications (narcotics) reconciliation was accurate for two narcotic medications (Lorazepam and Clonazepam) as evidenced by the number of total pills in bingo cards were less than the amount recorded on Medication Monitoring/ Control Record. There were 172 residents residing in the facility at the time of survey.

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreements presented to three residents (Resident number 83, Resident number 54 and Resident number 150) out of three residents reviewed informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 171 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate the implementation of effective plan of actions to correct identified deficiencies in problem areas, resulting in repeated deficient practices for F550 Residents Right/Exercise of Rights, as evidenced by the facility's failure to ensure six residents out of thirty-four sampled residents were treated in a dignified manner. There were 171 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain appropriate infection control standards related to biohazard disposal of wound dressing. As evidenced by soiled wound dressing observed on the floor in resident's room. There were 171 residents residing at the facility at the time of the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include; maintenance of air-conditioning vents to prevent food contamination, holding of hot and cold foods at regulatory requirement, proper use of the 3-compartment sink, replacement of worn food production equipment, handling of silverware in sanitary manner, maintenance of refrigeration equipment, handling of clean ice to prevent contamination, and ensure sanitary conditions in food storage and serving areas.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance service necessary to maintain a sanitary, orderly, and comfortable interior in 2 of 2 (first & second Floors) living area and 1 of 2 dining areas (second floor)

Inspectors wroteBased on interviews and record review the facility failed to maintain the combined Nursing, Certified Nursing Assistant (CNA), PCA (Personal Care Attendant) and Direct Care Staff minimum requirement of 3.6 hours weekly hours.

Inspectors wroteBased on record review, observations and interviews, the facility failed to perform Personal Care Attendant (PCA) competencies and failed to provide documentation of required training prior to have direct contact with the residents for 4 of 4 PCAs (Staff M, Staff N, Staff O and Staff W).

Inspectors wroteBased on observation and record review, the facility failed to ensure a medication error rate of less than 5%, during medication administration of 25 medications opportunities with two errors that were made during one observation, which gave an error rate of 8%.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to follow their policy of documenting the expiration date on 5 of 8 open eye drop vials, affecting Residents #43, #87, and #159; and failed to properly store and dispose of open medications in central supply.

Inspectors wroteBased on observation, record review and interview, it was determined that the approved menu was not followed potentially for 172 facility residents with physician ordered Therapeutic and Mechanically Altered diets. The menu was also not followed for 19 residents with Thickened Liquids that included Resident's #32, #51, and #64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services in a manner to maintain dignity for 3 of 3 sampled residents. The facility failed to ensure Residents #146 and #233 had clothing other than a hospital gown. Facility staff failed to speak to Resident #152 in a dignified manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a means of communication via a working telephone for residents throughout the third floor, including Residents #93 and 50. The facility failed to provide side rails per resident request for 1 of 1 resident reviewed for choices, #152

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide appropriate treatment and services to maintain or improve the ability to continue self-feeding for 1 (Resident #57) of 6 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure range of motion and mobility services was being provided for 3 of 3 sampled residents. The facility failed to ensure that splint devices were put in place as ordered/recommended by therapy for Residents #26 and #139. The facility failed to assist with recommended ambulation for Resident #146.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide 1 (Resident #149) of 6 sampled residents reviewed for nutrition adequate supervision and assistance during meals and prevent potential environment accidents 32 resident residing on Unit 2 which included sampled Resident's #132, #146, #152, #172, and #233.

Inspectors wroteBased on record review, observations and interviews the facility failed to assess for the removal of an indwelling urinary catheter and failed to follow up with hospital discharge recommendations to see a Urologist for alternative means of the use of the indwelling urinary catheter for 1 of 1 resident reviewed for perineal and urinary catheter care (Resident #151).