Sea Breeze Rehab and Nursing Center

Inspectors wroteBased on observation, interviews and record reviews the facility failed to treat residents in a dignified manner during dining for 2 of 5 residents (Resident #43, Resident #49) and for 2 of 5 residents for medication administration (Resident #95 and Resident #53), and 1 of 5 residents for catheter care (Resident #95).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure an informed consent for psychotropic medication(s) was obtained for residents prescribed psychotropic medications for 2 of 59 residents reviewed, who were receiving psychotropic medications, Resident #109 and Resident 25.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure resident rights were honored for 6 of 7 sampled residents as evidenced by the failure to ensure showers and/or honor shower preferences for Residents #15, #40, #38, #81, #95, and #112.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents' rooms were maintained in a safe, clean, homelike environment for 13 of 60 rooms, Rooms 210, 202, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, and128.

Inspectors wroteBased on policy review, interview and record review, the facility failed to implement their Grievance-Resident Rights policy for 3 of 3 sampled residents as evidenced by the failure to provide timely response to grievances for Residents #60, #25, and #95.

Inspectors wroteBased on interviews and record review, the facility failed to ensure PRN (as needed) orders for antipsychotic medications were limited to 14 days for 1 of 3 sampled residents receiving PRN psychotropic medications, Resident #109; and 1 of 5 sampled residents reviewed for unnecessary medications, Resident #39.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident's fingernails were cut and cleaned for 2 of 3 sampled residents reviewed for Activities of Daily Living (ADL) care, Residents #98 and #21.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure wound care orders were clarified and wound care was documented for 1 of 3 sampled residents reviewed for skin conditions, Resident #57; failed to ensure skin assessments were completed weekly for 1 of 3 sampled residents, Resident #3; failed to follow pharmacy review recommendation of not crushing medications for 1 of 5 sampled residents, Resident #3; and failed to give medication in timely manner for 3 of 3 sampled residents, Residents #38, #81 and #39.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure it followed physicians' catheter care orders or discontinue orders after catheter was removed for 2 of 2 sampled residents reviewed for catheter care, Resident #11 and Resident #95.

Inspectors wroteBased on observations interviews and record review, the facility failed to ensure physician's orders for tube feeding were follow and updated orders accordingly for 1 of 1 sampled resident reviewed for tube feeding, Resident #95.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure they obtained an assessment for bed rails, physician orders, a consent and a care plan for the bed rails was completed for 6 of 6 sampled residents reviewed for bed rails, Residents #3, #39, #49, #81, #95, and #112.

Inspectors wroteBased on interview and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 2 sampled residents reviewed for controlled substance reconciliation, Resident #87.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respond to the pharmacist's recommendations for Lidocaine patch to have a removal time and to specify the site of administration for 1 of 5 sampled residents identified for medication regimen review, Resident #4.

Inspectors wroteBased on observations, interviews and record review, the facility failed to monitor for behaviors and side effects for residents receiving psychotropic medications for 2 of 59 sampled residents receiving psychotropic medications, Residents #12 and #109.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 34.48% with 10 medication errors identified while observing a total of 29 opportunities, affecting Residents #95 and #78.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure medications were secure at all times for 4 of 6 medication (med) carts, and 3 of 5 medication pass observations, Residents #95 and #29, and for 1of 98 sampled residents, Resident #38.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy for cleaning and disinfecting resident-care equipment after obtaining blood pressure (BP) readings, affecting Resident #78; and after use of a Glucometer to test blood sugar levels, affecting Resident #29, during 2 of 5 medication administration observations; and failed to ensure hand hygiene was perform during medication administration for 2 of 5 medication administration observations, affecting Residents #31 and #78.

Inspectors wroteBased on the facility shower schedule, record review and interview, the facility failed to honor the shower preferences and schedules for 2 of 7 sampled residents reviewed for choices, Resident #14 and #48.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean comfortable homelike environment for 1 of 2 units, Unit B.

Inspectors wroteBased on policy review, interview and record review, the facility failed to respond to a verbal grievance regarding missing personal items for 1 of 1 voiced grievance, affecting Resident #13.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 23 sampled residents, as evidenced by improperly coding Resident #14 as comatose, inaccurate dental status for Residents #82 and 87, and an inaccurate hearing status for Resident #87.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement care plans for 2 of 23 sampled residents reviewed, Residents #87 and #15, as evidenced by lack of care plans related to hearing for Resident #87 and lack of care plans relating to self-administration of medication for Resident #15.

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic removal was recorded in the medication administration records (MARs) for 3 of 6 sampled residents reviewed, Residents # 28, # 6 and #9.

Inspectors wroteBased on record review, policy review and interview, the facility failed to prevent elopement; failed to thoroughly investigate the incident; failed to implement corrective measures to minimize reoccurrence and failed to report the adverse event. The failure affected 1 of 2 sampled residents, Resident #1.

Inspectors wroteBased on interview and record review, the facility failed to provide showers as per residents' choice and schedule for 2 of 4 sampled residents, Residents #37 and #14.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 2 of 5 sampled residents, related to medication use, Residents #54 and #52.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care and services for a Peripherally Inserted Central Catheter (PICC) line dressing change as ordered for 1 of 2 sampled residents with intravenous access, Resident #5.

Inspectors wroteBased on observations, interviews and record review, the facility failed to obtain a physician order for oxygen use for 1 of 3 sampled residents reviewed for respiratory issues, Resident #38; and failed to post 'oxygen in use' signage for 2 of 3 sampled residents reviewed for respiratory issues, Residents #38 and #6.

Inspectors wroteBased on record review and interview, the facility failed to ensure blood sugar monitoring, failed to follow blood pressure parameters with medication administration, and failed to ensure consistent and appropriate monitoring of medication side effects, all as per physician orders, for 3 of 5 sampled residents, Residents #36, #46, and #54.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure accuracy of medical records related to the administration of wound care and the provision of a Central Venous Catheter dressing change, for 2 of 2 sampled residents reviewed for wound care, Residents #15 and #52, and for 1 of 2 sampled residents with intravenous access, Resident #5.