Serenity Bay Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record reviews facility failed to store and prepare food in a sanitary manner in the kitchen as evidenced by milk box temperature measured at 50 degrees Fahrenheit, a refrigerated serving of nectar thick milk temperature measured at 51 degrees Fahrenheit, a personal item on top of dishwasher, and a kitchen staff member with a beard not wearing a beard covering. These deficient practices had the potential to result in food borne illness for all residents who consume food prepared in the facility's kitchen. There were 129 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interview, and record review, the facility failed to demonstrate and implement effective plan of actions to correct identified quality deficiency in the problem areas related to repeated deficient practice for F656-Develop/Implement Comprehensive Care Plan; F690- Bowel/Bladder; F761- Label/Store Drugs and Biologicals.; F812- Food Procurement, Store/Prepare/Serve Sanitary; there were 129 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record review, the facility failed to secure confidential information for residents on one (Unit 1) out of 3 units as evidenced by paperwork with residents' medical information left visible and unattended at the Unit 1 nursing station and an open, unattended computer screen with resident information visible on The Unit 1 medication cart 1. There were 129 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to implement the care plans for two (Resident #139 and Resident #142) out of two sampled as evidenced by: 1) The facility's staff positioned Resident #139's indwelling urinary catheter drainage collection bag above the bladder on the bed's side rail, causing backflow of urine in the tubing. 2) Facility staff failed to administer oxygen at the correct delivery flow rate setting for Resident # 139. 3) Facility's staff failed to follow infection control protocol related to Enhanced Barrier Precaution for Resident #142.

Inspectors wroteBased on observations, record reviews, and interviews, the facility created an unsafe environment with potential accidents and hazards for one resident (Resident #64) out of 2 residents sampled. An electrical cord extended from a wall to behind Resident #64's bed, causing a tripping hazard. This deficient practice increased the risk of accidents and hazards that could have caused serious harm or injuries. The facility had 129 residents at the time of the survey.

Inspectors wroteBased on observations, record reviews, and interviews, the facility's staff position an indwelling urinary catheter drainage bag and tubing in accordance with professional standards of care for one (Resident#139) out of three sampled residents, who had an indwelling urinary catheter. The facility's staff positioned Resident#139's indwelling urinary catheter drainage collection bag above the bladder on the bed's side rail, causing backflow of urine in the tubing. This increased the risk of catheter-associated urinary tract infections and other serious medical issues. Ten residents with indwelling urinary catheters resided in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide adequate respiratory care and services for one (Resident#139) out of two sampled residents receiving oxygen therapy, as evidence by inaccurate oxygen delivery flow rate setting for Resident # 139. This deficient practice increases the risk for worsening respiratory conditions with the potential of an adverse effect. There were 129 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations reviewed and interview the facility's staff failed to maintain the medication refrigerator temperature within the required range of 36 degrees Fahrenheit to 46 degrees Fahrenheit in one out of three medication room refrigerators. The refrigerator thermometer in Unit 3's medication room displayed a reading of 55 degrees Fahrenheit. There were 129 residents that resided in the facility at the time of survey.

Inspectors wroteBased on observations, record reviews, and interviews, the facility's staff failed to follow infection control protocol related to Enhanced Barrier Precaution for one resident (Resident #142) out of two sampled residents. The staff member did not wear the required Personal Protective Equipment during tracheostomy care, which increases the risk of transmitting Multidrug-Resistant Organisms. At the time of the survey, 129 residents resided in the facility.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for Unit #1 (13 resident rooms, 1 community shower room, and beauty salon/dialysis storage room), Unit #2 (13 resident rooms and 1 soiled utility room, and Unit #3 (23 resident rooms, 1 community shower and dining room).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation and interview it was determined that the facility failed to dispose of garbage and refuse properly.

Inspectors wroteBased on record reviews and interviews, the facility failed to obtain orders that accurately reflected code status for one (Resident #39) out of two residents reviewed for Advanced Directives.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure accuracy of medical personnel title for 1 of 29 sampled residents (Resident #32).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement care plans for the use of bed rails for 3 of 3 residents reviewed for bed rails, Residents #54, 5, and 120. The facility failed to develop and implement a care plan for a urinary catheter for 1 (Resident #7) of 1 resident reviewed for catheter.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to apply splint devices as ordered to prevent further decrease in range of motion for 1 of 1 resident reviewed, Resident #39.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to obtain physician's orders for an Indwelling urinary catheter and properly document the care for prevention of urinary tract infections for 1 out of 2 residents reviewed for bladder incontinence with an Indwelling Catheter (Resident #7).

Inspectors wroteBased on interviews and record reviews the facility failed to ensure timeliness of physician visits for 1 of 29 sampled residents (Resident #32).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to adequately monitor behaviors for residents receiving psychotropic medications for 5 out of 81 residents receiving psychotropic medications (Resident #32, 34, 96, 5, 116).

Inspectors wroteBased on observations record review and interview; the facility failed to secure medications at bedside for 1 of 29 sampled residents (Resident #34). As evidenced by medication (eye drops) observed on the resident's nightstand.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide food prepared in a pureed form designed to meet the needs of 2 sampled residents (Resident's #1, and #43) out of 12 facility residents with physician ordered pureed diet.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Discharge Minimum Data Set (MDS) assessment was submitted in a timely manner for one (Resident #95) out of one resident who was triggered for late MDS submissions. The MDS record was over 120 days old. There were 111 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident #110) out of one resident reviewed for resident assessments. Resident #110 was coded as being discharged to the hospital, but the resident was discharged home. There were 111 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, records reviewed and interview the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR). Level I for Serious Mental Illness (SMI) or Intellectual Disability (ID) was accurately completed at the time of admission for one resident (Resident #32) out of one resident whose PASRR was reviewed. This deficient practice has the potential to affect 111 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review, observations and interviews, the facility failed to implement a written care plan to ensure one (Resident #73) out of one resident reviewed for bowel and bladder incontinence received adequate incontinence care and ensure incontinent products were readily available for incontinence care. As evidence by Resident # 73 was left soiled for 3 hours by facility staff. 2) the facility failed to ensure care plan was implemented for the accurate provision of oxygen for two residents (Resident #514 and Resident #70) out of three residents reviewed for oxygen treatment. This has the potential to affect 14 residents receiving respiratory treatment. There were 111 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident #73) out of one resident reviewed for bowel and bladder incontinence received adequate incontinence care. Resident #73 did not receive incontinence care for over three hours. Incontinent products such as adult briefs were not readily available. The facility failed to ensure that residents requiring incontinent care had the needed supplies and were being checked and changed as needed in a timely manner based upon the resident's voiding pattern to meet professional standards of practice. This deficient practice has the potential to affect 73 residents receiving bowel incontinence care out of 111 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, record review and interview the facility failed to 1) ensure one (Resident #514) out of three residents reviewed for oxygen treatment received continuous oxygen treatments and 2) one resident (Resident #70) received the correct amount of oxygen out of three residents reviewed for oxygen treatment. This has the potential to affect 14 residents receiving respiratory treatment out of 111 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain communication with hospice to ensure continuation of care for 1 (Resident #79) out of 2 residents receiving hospice care, as evidenced by no updated hospice communication notes available in Resident #79's medical records. There were 111 residents residing in the facility at the time of this survey. The Findings Included: During observation on 1/17/23 at 8:50 AM Resident #79 was observed in bed, Tube feeing was running at 70 milliliters per hour (ML per Hr.), flush orders 30 ML per hr., Oxygen concentrator and nebulizer in room. On 01/18/23 at 08:36 AM Resident #79 observed in bed asleep, call light on bed Tube Feeding running at correct rate, no distress noted. During observation on 01/19/23 at 10:08 AM Resident#79 in bed laying down, eyes open, no distress noted, Tube Feeding running at correct rate. [...]

Inspectors wroteBased on record review and interview the facility failed to demonstrate Quality Assurance and Performance Improvement (QAPI) implemented effective plan of actions to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 645- Preadmission Screening and Resident Review (PASRR) and F 656- Develop/Implement Comprehensive Care Plans. These repeated deficient practices have the potential to increase the risk of negative resident outcomes and to affect all 111 residents residing in the facility at the time of this survey.