Seaside Hhc @ Atlantic Shore

Inspectors wroteBased on observation, resident interview and staff interview, the facility staff failed to ensure previous survey results were posted in a place readily available to residents, families and visitors.

Inspectors wroteBased on staff interviews and a clinical record review, the facility staff failed to review and revise the person-centered care plan for 1 of 21 residents (Resident #3) in the survey sample.

Inspectors wroteBased on observations, staff interviews, and a clinical record review, the facility staff failed to implement customary routines, interests, preferences, and choices for 1 of 21 residents (Resident #3) who exhibited episodes of inappropriate behaviors during activities of daily living (ADL) in the survey sample.

Inspectors wroteBased on observation and facility document review, the facility staff failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, to include the expiration date.

Inspectors wroteBased on observations, staff interviews, record reviews, and facility document reviews, the facility staff failed to maintain an effective infection control program that included a comprehensive surveillance system and effective infection control practices to prevent communicable diseases or infections in the one (1) nursing unit.

Inspectors wroteBased on staff interviews, record review, and facility document review, the facility staff failed to establish an effective infection prevention and control program (IPCP) that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use for facility residents.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure foods stored in the kitchen were labeled, dated when opened, sealed closed, and outdated food disposed. Also, employees failed to wash their hands when entering the kitchen and wear a hair covering. These failures had the potential to affect all 38 residents in the facility who ate food from the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two of three residents (Residents (R) 16 and R22) reviewed for liability notices out of a total sample of 17 residents. The form should have included the type of service provided and the estimated cost to continue receiving the services. The failure to provide the SNFABN prevented the responsible party the ability to make an informed decision related to the cost of continued therapy services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to address functional limited range of motion (ROM) for one (Resident (R) 15) reviewed for mobility/positioning in a total sample of 17 residents.

Inspectors wroteBased on observation, record review, interview statements and policy review, the facility failed to ensure that two (Resident (R) 85 and R8) of three residents reviewed for pressure sores received necessary treatment and services to promote healing. R85 had a delay in treating and completing an assessment of a known pressure ulcer upon admission and R8 did not receive a physician ordered treatment for an existing pressure ulcer.

Inspectors wroteBased on interviews, review of the staffing records, and facility policy review, the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for one of the 67 days reviewed (12/26/21).

Inspectors wroteBased on observations, interviews, and review of posted staffing information, the facility failed to ensure that staffing information included hours for all types of licensed nursing staff on duty, documented the current census, and was readily available to residents and visitors daily.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure face coverings were worn by all those who entered the facility to include vendors that made deliveries to the kitchen. On 1/6/22 at 11:45 AM observation of the lunch tray line was conducted with the Registered Dietician (RD) present. An outside bread vendor entered the kitchen without a mask, walked past the tray line and went into the storage room. The RD was asked why the vendor did not have on a mask to which the vendor had no response. The RD asked the vendor to put on a mask and he walked by the tray line and went into an office to obtain a mask. Interview on 1/6/22 at 11:53 AM with the vendor revealed that he always came through the back delivery door to enter the kitchen. He said he had never been asked to wear a mask. [...]

Inspectors wroteBased on staff interview, record review, facility policy review, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to offer and administer the pneumococcal vaccination in a manner consistent with CDC recommendations and professional standards. The failure affected three of five residents (Resident (R) 8, R15, and R17) reviewed for immunizations.

Inspectors wroteBased on medical record review, staff interviews and facility document review the facility staff failed to ensure that individual plan of care summary was sent with 3 of 22 Residents in the survey sample upon transfer to the hospital, Resident #22, #19, and #88. 1. The facility staff failed to ensure that Resident #22's plan of care summary was sent upon transfer to the hospital on 1/27/19. 2. Facility staff failed to send Resident #19's care plan summary when discharged to the hospital. 3. The facility staff failed to ensure Resident #88 plan of care summary was sent upon transfer to the hospital on 6/23/18 and 6/30/18.

Inspectors wroteBased on medical record review, staff interviews and facility document review the facility staff failed to ensure that a written notice of the Bed-Hold Policy was sent with 3 of 22 Residents in the survey sample upon transfer to the hospital, Resident #22, #19 and #88. 1. The facility staff failed to ensure that Resident #22 received a written notice of the Bed-Hold Policy upon transfer to the hospital on 1/27/19. 2. The facility staff failed to provide Resident #19 and/or Resident Representative a written Bed Hold Notice upon transfer to the hospital on [DATE]. 3. The facility staff failed to provide Resident #88 or resident representative with a written notice of the bed hold policy upon transfer to the hospital on 6/23/18 and 6/30/18.

Inspectors wroteBased on observations, staff interviews and facility document review, the facility staff failed to store and label food in accordance with food service safety guidelines.

Inspectors wroteBased on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide reasonable care for the protection of residents' property from loss for 1 of 22 residents (Resident #88) in the survey sample. The facility staff disposed of Resident #88's cards that had sentimental value.

Inspectors wroteBased on staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide appropriate indwelling Foley catheter care for 1 of 22 residents (Resident #88) in the survey sample. 1. The facility staff failed to provide appropriate indwelling Foley catheter care for Resident #88 daily for 5 days in June 2018.

Inspectors wroteBased on the observation of 2 medication carts and 1 medication room; the facility staff failed to dispose of medications on a discharged Resident # 191. The facility staff failed to dispose of an expired controlled medication (Fentanyl patch) and unidentified medications for Resident #191.