Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Beach Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Medication storage and administration practices were not followed when bags of meds for pharmacy return were left unattended, med and treatment carts were left unlocked, controlled drug counts did not match disposition records, discontinued and improperly dated eye drops remained on carts, and a discontinued antibiotic was still present. During med pass, an RN left prepared G-tube meds unattended and another RN nearly used insulin from the wrong resident because the ordered insulin was not available on the cart.
The facility failed to keep disposable towels available at the kitchen hand-washing sink, failed to store resident food in the freezer in a labeled and dated manner, and failed to keep the hydration cart sanitary when residents accessed the ice cooler and scoop directly. Surveyors observed outdated and unlabeled resident food in the freezer, and two residents with dementia-related diagnoses were seen opening the ice cooler and using the scoop without observed hand hygiene or gloves.
A facility failed to ensure medications and medication carts were properly secured and stored to prevent unauthorized access, despite a prior F761 citation for Labeling/Storage of Drugs and Biologicals on the previous survey. The Administrator stated the facility has a QAPI program and QAA Committee that meets monthly and monitors quality issues through audits, rounds, and data trending, but the report still identified repeated deficient practices related to medication storage and security.
A resident with CKD, AFib, severe protein-calorie malnutrition, DM, COPD, and depression was repeatedly served eggs at breakfast even after stating she did not eat eggs and had told staff this before. Observations showed egg items on her tray on multiple mornings, while the meal ticket initially did not list eggs as a dislike; the DON and CDM acknowledged that residents should be able to choose food options and that alternatives were available.
Failure to Protect Resident Confidential Information: Surveyors observed resident medical and personal information left visible and unattended at the front desk, North nurse's station, South Wing nursing station, and on a medication cart. The records included a Midnight Census, posted medical information, paperwork with confidential information, an open computer screen, and two binders with resident information. The DON and RN weekend supervisor stated that resident information should be kept confidential and not left visible in public areas.
A resident with DM, PVD, and a diabetic foot ulcer was observed in bed with both heels resting directly on the mattress and no pillow or offloading device in place, despite the care plan calling for heels to be floated while in bed. The wound care RN, an LPN, and the DON all confirmed that the resident’s heels were to be floated to prevent pressure injuries, but the intervention was not in place during the observations.
An unlocked, unattended housekeeping cart containing hazardous chemicals was observed on the North unit, and staff stated the cart should be locked because chemicals are kept inside. An unlocked Laundry Closet was also observed containing wound care supplies, including hydrocortisone cream, even though the DON stated the door locks from the inside and should remain locked. The facility policy stated the environment should be kept as free from accident hazards as possible and that resident safety and supervision are facility-wide priorities.
Two residents with urinary catheters were observed with tubing kinked or coiled, preventing free urine flow and leaving no urine in the drainage bag for one resident. One resident had a suprapubic catheter, recurrent UTI history, and a care plan to monitor for impaired drainage flow; the other had severe cognitive impairment, was dependent for toileting and hygiene, and had no catheter-specific care plan. Staff and the DON stated catheter tubing should remain straight and free of kinks to prevent back flow and infection.
Staffing information on the North Wing and South Wing was not kept readily available in a clear, readable format for residents and visitors. One wing’s assignment board was still showing the prior shift, while the other wing’s board was blank as an RN was rewriting the date, census, shift, and staff names. An RN stated the board had been wiped off for the next shift, and the DON said the staffing board should be updated every shift and be accurate.
The facility failed to maintain a safe environment as one out of three dryer lint traps in the laundry room was found full of lint. The cleaning log was missing signatures, and Staff D admitted to not cleaning the trap due to being busy, acknowledging the potential fire hazard. The facility also lacked a policy for cleaning lint traps.
The facility failed to notify the Ombudsman about the transfer of five residents to hospitals due to unsuccessful fax attempts. Despite ongoing issues with a busy fax line, the facility did not follow up for alternative communication methods until January 2025. The deficiency involved residents with various medical conditions, including COPD, acute respiratory failure, and diabetes, who were transferred without confirmed notification to the Ombudsman.
The facility failed to properly store and handle medications, as evidenced by discontinued drugs found on a cart, medications left unattended, and improper storage practices in the medication room. An LPN acknowledged the oversight, and an RN left medications unattended while searching for a disposal system. Personal items were found in the medication room, and insulin was improperly stored in a pocket. Medications were also found unattended in resident rooms, contrary to facility policy.
The facility failed to maintain sanitary food storage conditions, with the North Wing refrigerator operating at 50°F and lacking proper food dating, while the South Wing refrigerator lacked a thermometer. These issues were confirmed by staff interviews and photographic evidence.
The facility failed to follow infection control practices with a vital signs machine and laundry storage. An LPN did not disinfect a blood pressure machine after use, and clean curtains were improperly stored in the wash area. These actions were against the facility's infection control policies.
A facility failed to ensure a resident's emergency alert devices were accessible, as the call light and phone were observed out of reach on multiple occasions. The resident, diagnosed with epilepsy and requiring maximal assistance, had a care plan indicating a self-care deficit. Despite facility policies requiring call lights to be within reach, staff interviews confirmed the devices were not positioned correctly, highlighting a failure to accommodate the resident's needs.
A resident experienced a choking incident due to unblended food, which was necessary for their dietary needs. Despite the resident reporting the incident to an LPN, the nurse failed to document it or notify the physician, as required by the care plan. The Director of Nursing was unaware of the incident, highlighting a lapse in communication and documentation.
The facility failed to provide quality care for two residents, leading to a choking incident and improper meal positioning. A resident experienced food aspiration and was not assisted or reported by an LPN, while another resident was observed eating in a reclined position, contrary to care plan guidelines. Both incidents highlight lapses in documentation and adherence to care plans.
Two residents were found with prohibited items in their rooms, including cigarettes and a shaving razor, despite facility policies. A resident with quadriplegia had smoking materials in their room, while another resident with Major Depressive Disorder had a shaving razor. Staff were aware of these issues but failed to prevent the recurrence, leading to safety hazards.
The facility failed to address repeated deficiencies in reasonable accommodations, drug storage, and infection control, affecting 94 residents. Despite monthly QAPI meetings involving key staff, the facility did not effectively implement corrective actions to prevent these issues.
Medication Storage, Accountability, and Administration Failures
Penalty
Summary
Drugs and biologicals were not properly stored, accounted for, or dispensed in accordance with professional standards. During observation, surveyors found three bags of medications for pharmacy return left unattended on the counter at the South Unit nursing station, and both medication carts and treatment carts were observed unattended and unlocked. Staff stated that medication carts should be locked when not attended, and that medications being returned to the pharmacy should be scanned, placed in a bag, closed, and kept in the medication room, yet the observed bags were left on the nursing station counter and the carts were left open. A cart check and narcotic count on South Cart Two identified discrepancies in the controlled drug records and medication counts. For one resident receiving morphine sulfate ER, the bingo card count did not match the controlled drug disposition log. For another resident receiving oxycodone-acetaminophen, the count also did not match the log. For a third resident receiving oxycodone HCl, three single doses had been dispensed without corresponding date and time documentation showing administration by the LPN. For pregabalin, the bingo card count did not match the amount documented on the controlled drug disposition log. The LPN stated she should sign off for the medication when she takes it out, but she had not done so and could not explain why. Additional storage and administration issues were identified on medication carts and during medication pass observations. On one cart, ophthalmic solutions for residents had no open date, an incorrect open date, or an open date beyond the expected discard period, and a discontinued azithromycin tablet remained in a medication cart drawer. During a medication administration observation for one resident receiving G-tube medications, the RN placed the prepared medications on the overbed table and walked away, leaving them unattended. During another observation, an RN prepared to withdraw Novolog insulin for one resident but was holding insulin that belonged to another resident; the surveyor intervened, and the RN stated the resident’s insulin was not available on the cart. The facility’s policies stated that medications must be stored in their original packaging, carts must be locked when not in use, discontinued medications should be removed, and medications ordered for one resident may not be administered to another resident.
Kitchen hand hygiene, food storage, and hydration cart sanitation deficiencies
Penalty
Summary
The facility failed to have disposable towels available at the hand-washing sink in the kitchen for dietary staff. During the initial kitchen tour, the hand-washing sink had no disposable towels available for staff to dry their hands. A dietary aide stated that more towels had not been placed in the dispenser and would need to be added. The Certified Dietary Manager stated that dietary staff are supposed to wash their hands upon entering the kitchen and that soap, hand towels, and warm water should be available for them. The facility also failed to ensure resident food items were stored under sanitary conditions and properly labeled and dated in the freezer. During observation of the freezer used to store resident foods in the closed dining room, surveyors found outdated resident food that was not labeled, including a pasta dish dated 1/18/26 with ice particles on it and a frozen pizza with a room number that was not visible and no name label. In addition, the facility failed to ensure the hydration cart was handled in a sanitary manner when residents accessed it directly. Two residents, one with hemiplegia and dementia and another with dementia and diabetes mellitus, were observed going to the hydration cart, opening the ice cooler, and using the ice scoop to place ice in paper cups without being observed sanitizing their hands or wearing gloves. The DON stated that residents were not supposed to get their own ice and that staff were to assist them by giving them ice when requested.
Failure to Secure and Store Medications Properly
Penalty
Summary
The facility failed to demonstrate that effective plans of action were implemented to identify and correct repeated quality deficiencies related to F761, Labeling/Storage of Drugs and Biologicals. The survey history showed the facility had previously been cited under F761 during the prior survey dated February 13, 2025. At the time of the survey, there were 94 residents residing in the facility. During an interview on 02/04/2026, the Administrator stated that the facility has a QAPI program and a QAA Committee that meets monthly and as needed, and that the committee monitors quality issues through daily staff reports, audits, rounds, and data trending. The report also states that the facility failed to ensure medications and medication carts were properly secured and stored to prevent unauthorized access. The policy titled Quality Assurance /Quality Assurance Performance Improvement QAPI/QAA Goals/Purpose Statement described the facility’s purpose and stated that it monitors operations for compliance with federal and state regulations.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate one resident’s food preferences by repeatedly serving eggs despite the resident stating she did not eat eggs and had told staff this previously. During observations on multiple mornings, the resident was seen eating breakfast in bed while her tray included scrambled eggs or an egg omelet, and she stated each time that she was being given eggs again and would not eat them because of a bad experience with eggs. The resident’s meal ticket initially listed liked foods such as fortified foods and shakes, but eggs were not listed as a dislike until after the issue was identified. Record review showed the resident was admitted with chronic kidney disease, atrial fibrillation, severe protein-calorie malnutrition, anemia, diabetes mellitus, neuropathy, COPD, osteoarthritis, depression, insomnia, anxiety disorder, and major depressive disorder. Her MDS documented that she could make her needs known and required setup assistance for eating, and her physician orders included a regular diet with mechanical soft texture, thin liquids, and fortified foods. Interviews with the DON and CDM confirmed that residents are expected to be able to choose their food options and that food preferences are obtained on admission and as needed; the CDM also stated there were alternatives for residents who do not eat eggs and that the resident had the right to change her mind and have her choices.
Failure to Protect Resident Confidential Information
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential on both the South and North units. Survey observations found residents' medical information left visible and unattended at the front desk on top of the copy machine, a copy of the Midnight Census left on the North nurse's station counter, and residents' medical information posted on a wall in a highly visible area at the South Wing nursing station. Staff were informed of these concerns during the survey, and the DON later stated that medical information should be placed in a private area not visible to outside persons. Additional observations showed paperwork with a resident's confidential information visible and unattended at the North unit nursing station, an open computer screen with residents' medical information visible and unattended on South Wing Medication Cart #2, and an open computer screen with two binders containing residents' information left visible and unattended at the South Wing nursing station. The DON stated that HIPAA protects resident privacy and security and that resident information should not be left visible on computer screens or in public areas. Staff A, RN weekend supervisor, also stated that resident documents should not be left visible on counters or in public areas and that conversations about resident care should be kept private.
Failure to Float Heels for Resident With Diabetic Foot Ulcer
Penalty
Summary
The facility failed to provide ordered and planned care for a resident with a diabetic foot ulcer. Resident #89 was admitted with diagnoses including Type 2 diabetes mellitus with peripheral angiopathy with gangrene and peripheral vascular disease. The resident’s quarterly MDS showed moderate cognitive impairment, dependence for putting on and taking off footwear and transfers, partial moderate assistance needed for rolling left, and a diabetic foot ulcer. The care plan identified risk for skin impairment and pressure ulcers related to impaired mobility and included the intervention to float heels while in bed. During observations, Resident #89 was found in bed with a dressing on the left foot that did not cover the heel, and both heels were resting directly on the mattress with no pillow or offloading device present. A later observation again showed both heels resting directly on the bed with no pillow or offloading device present. The wound care RN stated the resident was at risk for pressure ulcer due to impaired mobility and that the heels are to be floated. An LPN stated the resident had a skin impairment on the heel and the heels are to be floated with a pillow, but the intervention was overlooked. The DON stated staff are to use soft boots or a pillow to float residents’ heels to prevent pressure injuries.
Unsecured housekeeping cart and unlocked supply closet
Penalty
Summary
The facility failed to ensure the environment remained free from accident hazards on the North unit. An observation on 02/08/26 at 10:08 AM revealed an unlocked, unattended housekeeping cart on the North unit, and the cart contained hazardous chemicals. At 10:10 AM, Staff H, housekeeping staff, stated the cart was supposed to be locked because chemicals are kept in it. During the laundry tour on 02/11/26 at 1:13 PM, the Housekeeping Director stated housekeeping carts should be kept locked to protect residents because there are chemicals in the carts. The facility also failed to keep a closet door that locks from the inside and contained wound care supplies locked. On 02/08/26 at 7:36 AM, an observation revealed a room marked Laundry Closet was unlocked and contained wound care supplies, including hydrocortisone cream. At 7:45 AM, the DON was made aware of the concern and stated the door locked from the inside and should remain locked. Record review of the facility policy titled, Safety and Supervision of Residents, revised July 2017, stated the facility strives to make the environment as free from accident hazards as possible and that resident safety and supervision are facility-wide priorities.
Kinked urinary catheter tubing prevented urine flow for two residents
Penalty
Summary
Staff failed to position indwelling urinary catheter tubing in accordance with professional standards for two residents. On 02/08/26, Resident #62 was observed in bed with suprapubic catheter tubing kinked so urine could not flow freely, and no urine was seen in the collection bag. Later that morning, the tubing was again observed coiled with urine present in the tubing. Resident #62’s record showed admission diagnoses including mechanical complication of a urinary catheter and UTI, an MDS indicating cognitive intactness, dependence for toileting, an indwelling catheter, and a UTI in the last 30 days, and a care plan addressing a suprapubic catheter with recurrent UTI and monitoring for impaired drainage flow. Resident #1 was also observed with indwelling urinary catheter tubing coiled and preventing urine flow, with no urine in the collection bag. Resident #1’s record showed orders for urinary catheter insertion for a 24-hour urine collection, severe cognitive impairment, and dependence for toileting and hygiene. The EHR contained no care plan specific to the indwelling urinary catheter. Staff interviews stated catheter tubing should be straightened and kept free of kinks to allow free flow of urine and prevent back flow and infection, and the facility policy required keeping catheter and tubing free of kinks and positioning the drainage bag lower than the bladder.
Staffing Boards Not Kept Current
Penalty
Summary
The facility failed to ensure that nurse staffing information on the North Wing and South Wing was readily available in a readable format to residents and visitors at any given time. The facility’s policy stated that direct care daily staffing numbers were to be posted within two hours of the beginning of each shift and include the date, census, shift, staffing types, actual time worked, and total number of licensed and non-licensed nursing staff working the posted shift. On 02/08/26 at 6:02 AM, the South Wing Nurses’ Assignment board was observed to still be dated 02/7/26 and showed the current shift as 3-11 PM. At 6:05 AM the North Wing Nurses’ board was observed blank while Staff L, RN was writing in the date, census, 11 PM-7 AM shift, and the names of the nurses and CNAs on duty. Staff A, RN stated she had wiped the board off for the next shift and confirmed the information should have remained posted. The DON stated the expectation was that the staffing board should be updated every shift and be accurate.
Failure to Maintain Safe Environment Due to Uncleaned Dryer Lint Trap
Penalty
Summary
The facility failed to provide a safe environment for its residents, as evidenced by an observation in the laundry room where one out of three dryer lint traps was found full of lint. This was discovered during a laundry tour conducted with the Director of Housekeeping. The lint trap in question was not cleaned, and the log that tracks the cleaning of lint traps was missing two signatures, with the last entry made the previous night. Staff D, responsible for housekeeping and laundry, admitted to not cleaning the lint trap due to being busy and acknowledged the potential fire hazard posed by the uncleaned lint trap. Additionally, the facility lacked a policy for the cleaning of lint traps, as confirmed by the Director of Nursing.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the Ombudsman about the transfer of five residents to the hospital, as evidenced by unsuccessful fax transmittals of the Notice of Transfer/Discharge Letter for November and December 2024. The residents involved were part of a sample of 23, with a total of 94 residents residing in the facility at the time of the survey. The deficiency was identified through record reviews and interviews, revealing that the facility did not confirm receipt of the notices by the Ombudsman. Resident #17 was transferred to a hospital for acute respiratory failure, and the fax notification to the Ombudsman was unsuccessful due to a busy line. Similarly, Resident #16 was transferred for a PEG tube placement, and the notification fax also encountered a busy signal. The medical records staff acknowledged the issue but did not follow up with the Ombudsman for an alternative method of communication. This pattern was consistent for Residents #10, #24, and #73, who were also transferred to hospitals without successful notification to the Ombudsman. Interviews with the Director of Nursing and medical records staff revealed ongoing issues with faxing the notices, with the Ombudsman line consistently busy. Despite attempts to contact the Ombudsman for an alternative number, the facility did not receive a resolution until January 2025, when the Ombudsman confirmed that they had not been receiving the forms and provided an email address for future communications. The facility's policy required that a copy of the transfer or discharge notice be sent to the Ombudsman at the same time it was provided to the resident and their representative, which was not adhered to in these cases.
Improper Storage and Handling of Medications
Penalty
Summary
The facility failed to ensure proper storage and handling of drugs and biologicals, as evidenced by several observations and interviews. Discontinued medication, Dificid (fidaxomicin) 200 mg, was found on a medication cart despite being discontinued on 12/24/24. Staff I, an LPN, acknowledged the oversight and mentioned that all nurses are responsible for checking their carts for discontinued and expired medications. Additionally, during a medication administration observation, Staff J, an RN, left medications unattended on a counter while searching for a drug disposal system, which was not readily available on the cart. Further observations revealed improper storage practices in the medication room, where staff's personal items were found on the counter, and the refrigerator for residents' food was noted to be at an improper temperature of 50 degrees Fahrenheit. An undated open bottle of sterile water for inhalation was also found in the medication room. Staff J, RN, was observed placing insulin in her pocket, which she later acknowledged was inappropriate. The DON confirmed that medications should not be left unattended and that personal items should not be stored in the medication room. Additional deficiencies were noted in resident rooms, where medications were found unattended. A medicine cup with a pill was observed on a bed next to a resident, and a bottle of Vitamin C was found in a nightstand drawer. Another resident had two inhalers hidden inside a tissue box, which were brought in by a family member. The facility's policy on medication labeling and storage was reviewed, indicating that medications should be stored in locked compartments under proper conditions, but these practices were not consistently followed.
Deficiency in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage of food, as evidenced by observations and interviews during a survey. On the North Wing, the nourishment pantry refrigerator was found to be operating at 50 degrees Fahrenheit, which is above the acceptable range of 35 to 40 degrees Fahrenheit. Additionally, three plastic bags containing residents' food were labeled but not dated, contrary to the facility's policy that requires all food to be dated to ensure proper rotation by expiration dates. Photographic evidence was submitted to support these findings. On the South Wing, the nourishment pantry refrigerator lacked a thermometer, making it impossible to monitor the temperature effectively. Although the residents' food in this refrigerator was dated and labeled, the absence of a thermometer was confirmed by a Licensed Practical Nurse (LPN) during an interview. The Director of Nursing (DON) also confirmed that the pantry refrigerator should have a thermometer, and the temperature should be maintained at 40 degrees Fahrenheit or below. The facility's records indicated that the temperatures were within the acceptable range earlier in the day, but the lack of a thermometer and the improper temperature on the North Wing suggest lapses in monitoring and maintaining food safety standards.
Infection Control Lapses in Vital Signs Machine and Laundry Storage
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, as observed with one of the two vital signs machines. A Licensed Practical Nurse (LPN) was seen measuring a resident's blood pressure and subsequently placing the used machine in the hallway without disinfecting it. The LPN admitted to forgetting to clean the machine, despite the facility's protocol requiring disinfection with sanitizing cloths after each use to prevent cross-contamination. The facility's policy mandates the use of standard precautions in all resident care situations, which was not followed in this instance. Additionally, during a laundry tour, clean curtains were found improperly stored in the wash area, partially covered in a plastic bag. This was contrary to the facility's policy, which requires the separation of soiled and clean linen to maintain aseptic conditions. The Director of Housekeeping acknowledged the storage issue, citing space constraints as the reason for storing clean linens in the wash area. These lapses in infection control practices were identified through observations, record reviews, and staff interviews.
Inaccessible Emergency Alert Devices for Resident
Penalty
Summary
The facility failed to ensure that a resident's emergency alert devices were accessible, as evidenced by observations of the resident's call light and phone being out of reach. During observations on two separate occasions, the resident was seen in bed with the call light hanging behind the bed and the phone placed on top of the overhead light, making them inaccessible. The resident, who has a clinical diagnosis of epilepsy and requires maximal assistance for care, was admitted to the facility with orders for bedrails for positioning and enabling. The resident's care plan indicates a self-care deficit and requires assistance with personal care tasks and mobility. Interviews with facility staff revealed that the call light should be within reach of residents at all times, and rounds should be conducted every two hours. The facility's policy on call lights mandates that they be accessible to residents when in bed, in the shower, or on the floor. Despite these policies, the resident's emergency alert devices were not positioned to allow the resident to call for assistance, indicating a failure to accommodate the resident's needs and preferences adequately.
Failure to Implement Nutritional Care Plan
Penalty
Summary
The facility failed to implement a nutritional care plan for a resident, resulting in a deficiency. The incident involved a resident who experienced a choking episode due to the inability to blend food, which was necessary for their dietary needs. The resident, who was cognitively intact, reported the incident to a Licensed Practical Nurse (LPN) after being assisted by a roommate. The LPN assessed the resident and found no immediate issues but failed to document the incident or notify the physician, as required by the care plan. The resident's care plan, initiated in December 2024, included monitoring for chewing and swallowing difficulties and notifying a physician if such issues were observed. Despite the resident's report of choking, the LPN did not follow these protocols. The Director of Nursing was unaware of the incident, indicating a lapse in communication and documentation. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, which were not adhered to in this case.
Failure to Prevent Aspiration and Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to provide quality care for Resident #297, who experienced a choking incident due to food aspiration. The resident, who requires a gluten-free diet with regular texture and thin liquids, reported that a chunk of food became lodged in their throat, necessitating intervention from a roommate. Despite the presence of a Licensed Practical Nurse (LPN) during the incident, the nurse did not intervene, document the event, or notify the physician, as required by the resident's care plan. The resident's care plan specifically included monitoring for signs of chewing or swallowing difficulties and notifying the physician if such issues were noted. The Director of Nursing was unaware of the incident, indicating a lapse in communication and documentation. Resident #398 was observed inappropriately positioned during meals, which could increase the risk of aspiration. The resident, who requires maximal assistance for care due to impaired mobility and generalized weakness, was seen slouched over and in a reclined position while eating. The care plan for this resident included the use of bedrails for positioning and enabling, yet the resident was not positioned at the recommended 45-to-90-degree angle during meals. An LPN confirmed that residents should be positioned correctly to prevent choking, but this was not adhered to in the case of Resident #398.
Inadequate Supervision and Safety Hazards in Resident Rooms
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free of safety hazards for two residents. Resident #9 was found with boxes of cigarettes and an electric cigarette in their room, despite the facility's policy prohibiting smoking materials in resident rooms. The resident, who is cognitively intact and requires assistance for certain activities, was aware of the smoking policy but continued to keep smoking materials in their room. Staff, including a CNA and the DON, were aware of the situation and had previously removed smoking items from the resident's room, but the resident continued to obtain more. Resident #17 was observed with a shaving razor in their room, which was brought in by the resident's son. The resident, who has a diagnosis of Major Depressive Disorder and requires assistance with activities of daily living, was not provided the razor by staff, and it was not noticed during rounds or hygiene care. The presence of the razor posed a potential safety hazard, especially given the resident's cognitive status and need for supervision. The facility's policies on smoking and safety were not effectively enforced, leading to these deficiencies. The smoking policy clearly states that smoking materials should be stored by staff and only used in designated areas, while the safety policy emphasizes the importance of a hazard-free environment. Despite these policies, the facility did not adequately prevent residents from having prohibited items in their rooms, resulting in safety hazards.
Repeated Deficiencies in Accommodations, Drug Storage, and Infection Control
Penalty
Summary
The facility failed to effectively implement plans of action to correctly identify and address quality deficiencies in several areas, including F558 Reasonable Accommodations Needs/Preferences, F761 Label/Store Drugs and Biologicals, and F880 Infection Prevention & Control. These deficiencies were identified during a recertification survey, with the exit date of August 31, 2023, and have the potential to affect 94 residents residing in the facility at the time of the survey. Specifically, the facility was cited for failing to ensure reasonable accommodations related to call lights, as well as issues related to the labeling and storage of drugs and biologicals, and infection prevention and control. The facility's Quality Assurance and Performance Improvement (QAPI) meetings, which are held monthly or as needed, involve a comprehensive team including the Administrator, Director of Nursing, and other department heads. Despite these meetings, the facility's efforts to monitor and communicate quality assurance issues with department heads were insufficient to prevent the recurrence of these deficiencies. The facility's QAPI goals emphasize providing excellent quality care and services, yet the repeated deficiencies indicate a gap between the stated goals and the actual implementation of effective corrective actions.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near North Miami Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Serenity Bay Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 14 | 0 |
| Regents Park At Aventura | 1.2 mi | ★★★★★ | 6 | 0 |
| Aventura Rehab And Nursing Center | 1.5 mi | ★★★★★ | 8 | 0 |
| The Lilac At Silver Palms | 1.7 mi | ★★★★★ | 13 | 0 |
| Vi At Aventura | 1.8 mi | ★★★★★ | 0 | 0 |
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