Seabreeze Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation of property and exploitation for 1 (Resident #1) of 8 residents reviewed for misappropriation and exploitation. The facility failed to ensure that Resident #1 was free from exploitation as evidenced by CNA A misappropriating funds from Resident #1's payment application. This failure could place residents at risk of misappropriation of property, financial hardship, and mental and emotional distress.

Inspectors wroteBased on observations, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Food items were observed stored in the facility refrigerator without proper sealing. This failure could place residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteThe facility failed to ensure, when a discharge was anticipated, to complete a discharge summary, including but not limited to, a recapitulation of stay, a reconciliation of pre-discharge medications, a final summary of the residents' status, and post-discharge plan of care Based on observation, interview and record review, the facility failed to ensure, when a discharge was anticipated for 1 of 3 residents reviewed for discharge summary (Resident # 60). --the facility failed to complete a discharge summary for Resident #60. This failure could place residents at risk of incomplete discharge records.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 5 residents (Resident #44) reviewed for PASRR.The facility failed to ensure that Resident #44's PASRR screening was updated accurately as evidenced by Form 1012 not being completed and submitted in a timely manner. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care or 1 or 1 resident (Resident #57) reviewed. The facility failed to complete the baseline care plan within the required 48-hour timeframe following admission for Resident #57. This failure could place the residents at risk for unmet care needs due to inconsistent care, or failure to receive required services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1 (Resident #61) of 5 residents reviewed for care plan. The facility failed to ensure that Resident #61's care plan was reviewed and revised regarding her weight changes and reflected both weight gains and losses. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and record review the facility failed to ensure the residents were being properly supervised to prevent accidents and hazards. The facility staff failed to ensure resident's environment was safe and free from any potential harm. LVN-B did in fact bring in a weapon namely a pellet gun into the facility. The facility failed to ensure that facility staff were trained on how to properly ensure the resident environment remains as free of accident hazards as possible.

Inspectors wroteBased on interview, and record review the facility failed to ensure that Resident#1 medications were properly stored. The facility staff failed to ensure that resident's medication was stored and secured in a secure manner. LVN-A did not secure her keys, nor did she ensure that the med room was secure. As a result, Norco drugs were unaccounted for. This failure could place residents at risk of not having their prescribed medications given to them as directed according to physician orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse, neglect, exploitation or mistreatment for 5 of 73 residents (Resident #8, Resident #12, Resident #18, Resident #20, and Resident #30) reviewed for abuse and neglect in that: The facility failed to ensure residents at the facility were provided with hot water and baths/showers for a month, that would allow them to maintain cleanliness and access to activities of daily living. The facility negelcted to provide hot water in the facility for over a month. The residents in the building had not had showers in weeks and there was no documentation to show that residents had a bed bath or a shower for the month of September. -The facility neglected to ensure residents at the facility were relieved from filth, and distress. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for 5 (Resident #8, Resident #12, Resident #18, Resident #20, Resident #30) of 73 residents reviewed for ADL care, in that: The facility failed to ensure residents at the facility were provided with hot water and baths/showers for a month, that would allow them to maintain cleanliness and access to activities of daily living. There had been no hot water in the facility for over a month. The residents in the building had not had showers in weeks and there was no documentation to show that residents had a bed bath or a shower for the month of September. -Resident #8 had cried to staff about her discomfort of not having a bed bath or shower in weeks. -Resident #12 was diagnosed with the need for assistance with personal care. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plane, and the resident's choices for 1 (Resident #18) of 73 residents reviewed for quality of care. The facility failed to apply compression wraps to Resident #18's legs as ordered and Resident #18 experienced increased swelling and discomfort in her lower extremities. This failure placed resident at risk for further injury or harm.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 9 of 61 days reviewed for staffing, in that: There was no proof of RN coverage for 9 days of 61 days reviewed for RN coverage. This failure placeds all residents at risk of not receiving adequate medical care and supervision of an RN.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment (boiler room equipment) in safe operating condition for 1 of 1 hot water heater heaters system in the facility in that - The facility did not have hot water for resident's use in two weeks . This failure could place the residents at risk of not having their ADL care in a timely manner and as needed.

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (Resident #19) of 8 residents reviewed for base-line care plans. The facility failed to ensure (Resident #19) had a baseline care plan developed within 48-hours after admission with goals, services, and interventions. The failure could place newly admitted residents at risks of not receiving the care and services for health promotion and continuity of care.

Inspectors wroteBased on interviews and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of controlled medications for 1 of 6 residents (Residents #60) reviewed for pharmaceutical services. The facility failed to ensure that LVN A accurately documented on the narcotic count sheet for Resident #60's scheduled pain medication administration for Percocet 5/325 mg. This failure could place residents at risk of misappropriation by drug diversion and could result in diminished health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices for 1 of 18 residents reviewed for clinical record accuracy (Resident # 2). --the facility did not have documentation of the results of Resident # 2' s PASRR evaluation in the resident's clinical record. This failure could place residents at risk of having incomplete clinical records and decrease in staff knowledge of resident's medical history.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, leading to potential entrapment hazards for 1 (Resident #49) of 13 residents reviewed for safety in rooms. The facility failed to conduct regular inspections of resident bed frames and mattresses to identify risks and problems. Resident #49's bed had a significant gap between the mattress and bedframe. The mattress was torn with mattress foam coming away from the mattress cover and was covered with stains and rips in the center of the mattress. The finding Include: Record review on 9/24/24 at 9:00 am of Resident #49 admission face sheet revealed she was a [AGE] year-old female with Parkinson's, osteomyelitis, and dementia. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to obtain laboratory services when ordered by a physician in accordance with the State law, including scope of practice laws for 1 of 12 residents (CR #1) reviewed for laboratory services. 1. LVN A failed to document physician's orders and obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by CR #1's infectious disease physician when she was discharged from an acute care hospital on [DATE] and resulted in re-hospitalization on 04/16/2024 with elevated WBC values, which indicated infection. 2. LVN A failed to document physician's orders and obtain weekly laboratory services (BMP and CBC) as ordered by CR #1's NP when she reconciled (the process of comparing a patient's medication orders) medication orders on 03/29/2024 and resulted in re-hospitalization on 04/16/2024. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 4 of 17 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for smoking. 1. The facility failed to ensure Resident #1 had proper supervision after her smoke assessment stated she was careless with smoking materials and dropped ashes on herself. Her care plan stated she needed an extender and apron to be safe. She was observed without supervision, an apron or extender. 2. The facility failed to ensure Resident #2 had proper supervision after he was found smoking in his room located in the memory care unit. He was supposed to be supervised by his family member. His family member was not supervising him upon observation. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 21 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. 1. The facility failed to effectively intervene or follow their own smoking policy when Resident #1 was known to drop cigarette ashes on herself. 2. The facility failed to implement their own policy when resident #2, a memory care resident had smoked in his room. 3. The facility failed to implement their own policy when Resident #3 was known to be non-compliant and placed a half-smoked cigarette that she had just extinguished into a paper bag. These failures placed smoking residents at risk for injury from burns and fires caused by hazardous smoking behaviors. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #5) out of 3 residents reviewed for wound care. In that, The facility failed to ensure Resident #5's wound vac was applied on her wound as ordered by the physician. This failure could expose residents to low quality of care, worsening of condition, hospitalization, and death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 (Resident #5) of 3 residents reviewed for wound care. In that, The facility failed to ensure Resident #5's wound vac was applied on her wound as ordered by the physician. This deficient practice could place residents at-risk for improper care practices, infection, injury, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical record in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #8) reviewed for medical records, in that: Facility failed to ensure Resident #8's list of medication during discharge was kept in the medical record with the facility. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication and delay in services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 3 of 11 residents reviewed for ADL care (Residents #1, #2, #3). Facility staff failed to provide personal hygiene care to Residents #1, #2, & #3. These failure failures placed residents who were unable to carry out ADLs at risk of not receiving necessary care and assistance when needed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (Resident #70) of 18 reviewed for abuse. The facility failed to ensure Resident #70, who was cognitively impaired, had a history of aggressive behaviors, and resided in the facility's memory care unit, was free from abuse when she was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. The IJ template was provided to the facility on [DATE] at 5:40 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 18 residents (Resident #70) reviewed for abuse. The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and report an allegation of abuse in the facility's locked memory care unit when Resident #70, who was cognitively impaired and had a history of aggressive behaviors, was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment for 3 of 18 (Residents #2 #4, #56,) residents reviewed for resident assessments in that: 1 Resident #2 Resident most recent comprehensive annual assessment did not accurately reflect her hearing deficit and oral dental status. 2 Resident #4's most recent comprehensive assessment did not include his cognitive level, mood, oral dental status, and his dysphasia status (swallowing disorder). 3 Resident #56's most recent comprehensive assessment did not include his diagnoses of dental root caries, Quadriplegia, Anxiety disorder These failures could place residents at risk of not receiving care and services needed to attain/maintain their highest practicable quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 6 of 18 residents reviewed for care plan accuracy (Residents #7, 20, 28, 32, 49, 60). --Resident #7 was not care planned for Dialysis --Resident #28 did not have a care plan for incontinence --Resident # 20, #28 and Resident # 49's care plans did not specify level of assistance needed for ADL care --Resident #32's care plan was not updated for room placement --Resident # 49 did not have a care plan for Hospice --Resident #60 was not care planned for Dialysis These failures placed residents at risk of not receiving care and services needed to maintain their highest practicable quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 8 of 18 residents reviewed for ADL care (Residents # 4, #7, #20, #28, #44, #55, #60, #181). --facility staff failed to provide personal hygiene care to Resident #4, #44, #55, #60 --facility staff failed to turn and reposition Resident # 7 as ordered --facility staff failed to provide timely incontinent care and transfer assistance to Resident #20 ---facility staff failed to provide timely incontinent care to Resident # 28, #55, #60, #181 Theis failurefailures placed residents who were unable to carry out ADLs at risk of not receiving necessary care and assistance when needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to assure that there were sufficient qualified nursing staff available to provide nursing and related services to meet the residents' needs and safely in a manner that promotes physical, mental, and psychosocial well-being for 6 of 18 residents ( Resident #4, #7,#20,#44, #55, #60), reviewed for Quality of care. --The facility failed to provide Resident #4 with ADL care scheduled. --The facility failed to provide Resident #44 with ADL care scheduled. --The facility failed to provide Resident #7 with ADL care scheduled. --The facility failed to provide Resident #20 with ADL care scheduled. -The facility failed to provide Resident #55 with ADL care scheduled. [...]

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 8 days in May of 2023 and 3 days in June of 2023 . The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 11 of 62 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: -The facility failed to ensure that one of one tabletop can opener was clean. -The facility failed to ensure that left over food items in the walk-in cooler were appropriately dated, labeled, and sealed. -Tthe facility failed to ensure that expired milk was not served to resident for consumption. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #12, #42, and #4) of 18 residents observed for infection control, in that: 1. Resident #12 had a foley catheter bag (a bag that contains urine) dragging on the floor throughout the facility while he was in his wheelchair and was leaking along the way. 2. Resident #42 was given oral medications by LVN D without washing her hands beforehand, and with bare hands. 3. Resident #4 had wound care performed by Dr. B without gloves being changed between the dirty dressing removal and a clean dressing applied. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 13 (Resident rooms 100, 101, 102, 103, 105, 107, 109, 111, 115, 117, 119, 121, and 215) out of 27 resident rooms reviewed for environment. The facility failed to have a working light on the outside of the room that would light up when the resident pushed the call bell for Resident rooms 100, 101, 102, 103, 105, 107, 109, 111, 115, 117, 119, 121, and 215. This failure could place residents at risk of not being able to get staff assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, comfortable environment for residents, staff, and the public in interior of the facility, and in 4 resident rooms (rooms 100, 120, 122, 124). --Resident rooms 100, 122, 124 were hot and did not have operating air conditioners --bathroom sink in room [ROOM NUMBER] had water gushing onto the floor when it was turned on --scrapes on the wall with damage to paint and sheetrock in room [ROOM NUMBER] --broken, missing tiles in laundry room These failures could place residents, staff, and visitors at risk of living and working in an unsafe uncomfortable environment, exposure to infection or disease and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests in 6 (room [ROOM NUMBER], 106, 110, 122, 123, and 206) of 18 resident rooms, the North side shower, the North side resident hall, and the North side conference room. 1. There were flies in resident rooms 100, 106, 110, 122, 123, 206 and the North Side conference room. 2. There was a large roach in resident room [ROOM NUMBER] and on the North side resident hall. 3. There were gnats in the North side shower. These failures could place residents at risk for the potential spread of infection, cross contamination, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours if the alleged violation resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency for 1 of 18 residents (Resident #70) reviewed for abuse, neglect, and injuries of unknown origin. 1. The facility failed to thoroughly investigate and report an allegation of abuse for Resident #70 reported on 7/17/23. 2. The facility failed to report Resident #70's injury of unknown source from an unwitnessed fall on 7/6/23. This failure could affect residents by placing them at risk of not having incidents of abuse or neglect, reviewed, and investigated in a timely manner by the facility and State Survey Agency.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #7) of 2 residents reviewed for gastrostomy tube management. The facility failed to follow the physician orders for Resident #7's enteral water flush (a set amount of water that is delivered into the digestive system via the feeding tube). This failure could place residents at risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #72) of 3 residents sampled for respiratory care. The facility failed to get an order for Resident #72's oxygen and he was using it without an MD's prescription. This failure could place residents at harm of receiving unnecessary treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 5 residents (Resident #72 and #20) reviewed for pharmaceutical services in that: 1. Resident #72 was not given hydrocodone-acetaminophen 7.5mg-325mg (a medicine for pain) for 3 hours after he requested it. 2. Resident #20 was not given her bisacodyl suppository 10mg (medicine for bowel movement) even though it was ordered PRN. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and uncontrolled pain.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for 1 (Resident #20) of 18 residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #20's food preferences of vegetarian and gluten free. This failure could place residents at risk of not having their food preferences met which could cause weight loss and a decline in their quality of life.