Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Serenity Bay Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen food storage and hygiene practices were deficient when a milk box refrigerator and a serving of nectar thick milk were found above the required cold holding temperature, expired dishwasher sanitizer test strips were in use, a Styrofoam cup was observed on top of the dishwashing machine and then emptied into a utensil bin, and a porter with a beard was seen carrying food without a beard covering. Facility policy required dietary staff to wear hair restraints, including beard restraints, to prevent hair from contacting food.
Repeated QAPI deficiencies were cited for F656, F690, F761, and F812 after surveyors found the facility had not demonstrated an effective plan of action to correct prior problem areas. Survey history showed the same deficient practices had been cited before, including food service sanitation issues, while the Administrator/QA and DON stated the QAPI committee meets monthly to review prior month findings and discuss opportunities for improvement.
A facility failed to keep resident records private on Unit 1 when surveyors observed unattended paperwork with resident names and medical information visible at the nursing station and an open, unattended computer screen on a med cart showing resident information. The RN Manager stated information should not be viewable to people walking by, and an RN acknowledged the open screen and closed it. The facility's HIPAA sanctions policy identifies leaving a secured application unattended while logged on as a violation.
Failure to Follow Catheter, Oxygen, and EBP Care Plans: A resident with an indwelling urinary catheter was observed with the drainage bag positioned above the bladder and urine backflow in the tubing, despite the care plan directing the bag and tubing to remain below bladder level. The same resident was also observed receiving O2 at 5 LPM when the order and care plan called for 4 LPM continuously. In a separate event, an RN provided tracheostomy care to another resident without wearing a gown, despite an order and care plan for EBP requiring gown and gloves for high-contact care.
An unsafe environment was created when an electrical cord was observed extending from the wall to behind a resident’s bed and remained in place during repeat observation. The resident had severe cognitive impairment, used a walker and wheelchair, and was care planned for fall risk due to a history of falls and unsteady gait. The DON acknowledged the cord was not supposed to be there, while the Maintenance Director and an LPN stated cords should be positioned behind the bed to avoid tripping hazards.
A resident with an indwelling urinary catheter had the drainage bag positioned above bladder level on the bed side rail, and urine backflow was observed in the tubing. The resident had obstructive uropathy, UTI, and ESRD, and the care plan directed staff to keep the bag and tubing below bladder level. Staff interviews confirmed expectations for catheter bag placement below the bladder to prevent reflux and UTI.
A resident with COPD, acute respiratory failure with hypoxia, and pleural effusion was observed receiving oxygen via nasal cannula at 5 LPM, although the physician order and care plan directed 4 LPM continuously. An RN confirmed the oxygen should have been at 4 LPM, and the DON stated nurses are to follow physician orders when administering oxygen.
An LPN observed a medication room refrigerator with an internal temperature of 55 degrees Fahrenheit, while the log outside the refrigerator showed 39 degrees Fahrenheit. The LPN stated they did not know the proper refrigerator temperature, and the pharmacist confirmed the required range is 36 to 46 degrees Fahrenheit. Facility policy also required refrigerated medications to be stored at 36 to 46 degrees Fahrenheit with daily temperature checks.
A resident with tracheostomy status and an order for EBP to prevent MDRO transmission received tracheostomy care from an RN who was not wearing the required disposable gown throughout the procedure. The resident's care plan required gown and gloves for tracheostomy care, and the RN stated the gown, gloves, and face mask should have been worn but were not because that part was missed.
The facility failed to adhere to food safety standards, with issues such as leaks and condensation in the kitchen, improper dishwashing and sanitizing processes, and unsanitary handling of food and equipment. Observations revealed potential contamination risks from dripping water, improper thawing of raw chicken, and inadequate sanitizing chemical levels. Additionally, broken equipment, rust, and improper food handling practices were noted, compromising food safety and sanitation.
The facility failed to properly dispose of garbage and refuse, with an overflowing dumpster and broken bags of trash spilling onto the ground. Additional bags of trash and nursing waste were stored on the ground, with many ripped open, scattering trash and soiled PPE supplies. The Administrator cited recent flooding as a cause for delayed trash pick-up.
The facility failed to maintain a sanitary and comfortable environment across multiple units, with issues such as damaged walls, short privacy curtains, and malfunctioning equipment. Units exhibited strong odors, mold-like matter, and improper storage of supplies. Despite maintenance logs, staff did not effectively address these issues.
A facility failed to document a resident's code status, resulting in a deficiency. The resident, with multiple health conditions, lacked a documented code status in their electronic health record. Interviews revealed unclear responsibilities among staff for ensuring code status documentation, with the DON noting previous staff turnover as a potential factor.
A facility failed to accurately record the title of a medical professional in a resident's records. A resident with mental health diagnoses was seen by a Nurse Practitioner, but the EMR incorrectly identified the NP as a physician. Interviews revealed confusion between the DON and Admission Director over who was responsible for entering and verifying medical personnel titles.
The facility failed to develop care plans for bed rails for three residents and a urinary catheter for another. Despite policies requiring documentation, care plans were missing, and staff interviews revealed confusion over responsibilities. Observations noted inappropriate use of materials on bed rails, and a resident's catheter was not addressed in their care plan, indicating gaps in care planning.
A resident with cognitive impairment and bilateral extremity impairments did not receive prescribed splint devices to prevent further contractures. Observations showed the resident without splints on multiple occasions, and staff interviews revealed inconsistencies in applying the devices. There was no documentation of the resident's intolerance or removal of the splints, despite staff acknowledging these occurrences.
A facility failed to obtain physician's orders and document care for a resident with an indwelling catheter, despite the resident's history of UTIs and related diagnoses. Staff interviews confirmed the absence of orders and documentation, although the resident had the catheter for months. The facility's policy requires physician orders and appropriate care to prevent UTIs, which were not followed.
A resident was not seen by their primary physician for six months, contrary to the facility's policy requiring regular visits. Instead, the resident was seen by a Nurse Practitioner and a Physician's Assistant. The Director of Nursing acknowledged responsibility for ensuring timely visits, but the Primary Care Physician indicated a lack of coordination in scheduling, leading to the oversight.
The facility failed to adequately monitor and document behaviors for residents on psychotropic medications, leading to deficiencies in medication management. Residents exhibited behaviors that were not properly recorded, and staff expressed confusion about documentation procedures.
A resident's eye drops were improperly stored on their nightstand, contrary to the facility's policy requiring locked storage. The LPN was unable to confirm if the eye drops were the prescribed artificial tears, and the consultant pharmacist confirmed they were not a substitute for the ordered medication.
The facility failed to provide properly pureed foods for residents with physician-ordered pureed diets. Observations revealed that both breakfast eggs and lunch fish were not pureed to the required smooth consistency. The Registered Dietitian confirmed the improper texture, and the breakfast cook had not been trained in preparing pureed foods. Two residents with dysphagia and severe cognitive impairment were affected.
Kitchen Food Storage and Personal Hygiene Deficiencies
Penalty
Summary
Food was not stored and prepared in a sanitary manner in the kitchen. During the initial kitchen tour, the Milk Box Refrigerator was measured at 50 degrees Fahrenheit and a serving of nectar thick milk in the Milk Box was measured at 51 degrees Fahrenheit, while Refrigerator #2 measured 42 degrees Fahrenheit. The dishwasher sanitizer test strips in use were expired, with an expiration date of October 1, 2025, and new unexpired strips were provided after the concern was identified. At 11:00 AM, a Styrofoam cup was observed on top of the dishwashing machine while a porter was standing beside it. The porter stated the cup had been picked up and sipped from, then dumped the remaining liquid into a utensil bin, and the Kitchen Manager stated the bin could not be sent through the dishwasher alone due to contamination. Later, a porter with a beard was observed carrying a tray of food without a beard covering. The porter stated they were new and had been told to wear a covering, and the Kitchen Manager stated staff are aware they need to wear a beard covering. The facility policy required dietary staff to wear hair restraints, including beard restraints, to prevent hair from contacting food.
Repeated QAPI Deficiencies and Failure to Correct Identified Problem Areas
Penalty
Summary
The facility failed to demonstrate and implement an effective plan of action to correct repeated quality deficiencies identified in prior survey history. The cited problem areas included F656-Develop/Implement Comprehensive Care Plan, F690-Bowel/Bladder, F761-Label/Store Drugs and Biologicals, and F812-Food Procurement, Store/Prepare/Serve Sanitary. The report states that during the recertification survey conducted from June 17, 2024 through June 20, 2024, these deficiencies were cited again, and the facility had 129 residents at the time of survey. The facility’s survey history showed repeated deficient practice in the same areas, including failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during observations. The facility policy titled Quality Assurance and Performance Improvement states that the facility is to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program focused on indicators of outcomes of care and quality of life. During interview, the Administrator/QA and DON stated that QAPI meetings are normally held monthly and that the committee reviews issues and findings from the prior month, with members including nursing, infection prevention, dietary, social services, activities, housekeeping, administration, and admissions leadership.
Failure to Protect Resident Confidential Information
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential on one of three units. On Unit 1, surveyors observed unattended paperwork containing residents' names and medical information left visible at the nursing station, and an open, unattended computer screen on medication cart 1 with resident information visible. The Unit 1 RN Manager stated that no information should be viewable to people walking by and that all information on computers should be kept private. Staff H, RN, also acknowledged the open computer screen and closed it. The facility policy titled HIPAA Sanctions states that employees are expected to protect residents' personally identifiable health information and identifies leaving a secured application unattended while logged on as a violation.
Failure to Follow Catheter, Oxygen, and EBP Care Plans
Penalty
Summary
The facility failed to implement the care plan for a resident with an indwelling urinary catheter. During an observation, the resident’s catheter drainage collection bag was found anchored to the bed’s side rail above the level of the bladder, and backflow of urine was observed in the tubing. The resident had diagnoses including obstructive uropathy, urinary tract infection, and end stage renal disease. The care plan directed staff to position the catheter bag and tubing below the level of the bladder, and the DON stated staff are to position the bag below the level of the bladder because backflow can cause a UTI. The facility also failed to follow the resident’s oxygen order and care plan. The resident was observed receiving oxygen via nasal cannula at 5 LPM, although the physician’s order and care plan directed oxygen at 4 LPM continuously. In addition, the facility failed to follow Enhanced Barrier Precaution for another resident with tracheostomy status. During tracheostomy care, an RN was observed not wearing a disposable gown, even though the resident’s order and care plan required EBP with gown and gloves for high-contact care, and the RN stated the gown was not worn because that part was missed.
Electrical Cord Left as a Tripping Hazard Near Resident Bed
Penalty
Summary
The facility created an unsafe environment with potential accidents and hazards for Resident #64 when an electrical cord was observed extending from the wall to behind the resident’s bed. The cord was seen in the room on 12/02/2025 at 11:07 AM and was still present during a later observation at 12:34 PM. The Director of Nursing acknowledged the concern and stated that the cord was not supposed to be there and that it would be removed. Resident #64 was initially admitted and later readmitted with a diagnosis including idiopathic Normal Pressure Hydrocephalus. The quarterly MDS dated 11/19/2025 showed the resident was severely cognitively impaired, used a walker and wheelchair, had no impairment to upper or lower extremities, and received antipsychotics on a routine basis. The care plan identified the resident as at risk for falls due to a history of falls and unsteady gait, with an intervention to keep the environment clear of clutter and obstacles. The Maintenance Director stated the cord should have been plugged behind the bed to prevent tripping, and an LPN stated cords should be plugged in the nearest outlet behind the bed and not across the area as observed.
Improper Positioning of Indwelling Urinary Catheter Drainage Bag
Penalty
Summary
Appropriate care for residents with indwelling urinary catheters was not provided for one resident when staff positioned the catheter drainage collection bag above the level of the bladder on the bed's side rail. During an observation, the bag was seen anchored above the bladder with backflow of urine visible in the tubing. The resident had diagnoses including obstructive uropathy, UTI, and end stage renal disease, and the care plan directed staff to position the catheter bag and tubing below the level of the bladder to remain free from catheter-related trauma and signs or symptoms of urinary infection. Record review showed the resident's admission MDS was in progress. Staff interviews indicated the RN stated she rounds every two hours and said the bag was below the bladder when she came on shift, while the CNA stated she makes sure catheter bags are inside a cover, not touching the ground, and below bladder level, but did not notice the bag was on the side rail. The Infection Control Preventionist stated staff are educated to ensure tubing is below the bladder and not kinked because urine can reflux back into the bladder and cause urinary infection, and the DON stated staff are to position the bag below bladder level because backflow can cause a UTI. The facility had 10 residents with indwelling urinary catheters at the time of the survey.
Inaccurate Oxygen Flow Rate
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident receiving oxygen therapy. Resident #139, who had diagnoses including COPD, acute respiratory failure with hypoxia, and pleural effusion, was observed in bed receiving oxygen via nasal cannula at 5 LPM. The physician’s order dated 11/19/25 directed oxygen at 4 LPM via nasal cannula continuously every shift for preventative measures, and the care plan also identified oxygen at 4 LPM continuously for the resident’s COPD-related breathing risk. When the concern was identified, an RN stated that the oxygen should have been delivered at 4 LPM. The DON stated that nurses are to follow physician orders when administering oxygen. The facility policy on physician orders stated that all physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident’s medical record during that shift.
Medication Refrigerator Temperature Out of Range
Penalty
Summary
The facility failed to maintain the medication refrigerator temperature within the required range of 36 degrees Fahrenheit to 46 degrees Fahrenheit in one of three medication room refrigerators. During observation of Unit 3's medication room with an LPN, the temperature log outside the refrigerator showed a documented reading of 39 degrees Fahrenheit, but the thermometer inside the refrigerator displayed 55 degrees Fahrenheit. The LPN stated they did not know the proper temperature for the refrigerator. The pharmacist later stated that the medication room refrigerator temperature should be between 36 and 46 degrees Fahrenheit. The facility policy on Medication Storage, dated 05/01/2023, states that refrigerated medications are stored in refrigerators in the pharmacy and each medication room, temperatures are maintained within 36 to 46 degrees Fahrenheit, and temperatures are recorded daily by the charge nurse or designee.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to follow infection control protocol related to Enhanced Barrier Precaution for Resident #142 during tracheostomy care. On observation, Staff D, RN provided tracheostomy care without wearing a disposable gown throughout the procedure. The resident was initially admitted and later readmitted with a diagnosis that included tracheostomy status, and a physician's order dated 11/21/25 directed Enhanced Barrier Precaution to prevent transmission of multidrug-resistant organisms related to the presence of a tracheostomy every shift. Record review showed the resident's MDS dated 11/26/25 indicated a BIMS score of 15 with no cognitive impairment, substantial assistance for oral hygiene, and receipt of tracheostomy care, continuous oxygen therapy, and suctioning as needed. The care plan initiated on 11/21/25 and revised on 11/30/25 required Enhanced Barrier Precautions for tracheostomy, including staff wearing gown and gloves for high-contact care areas and for tracheostomy care. During interview, Staff D stated a gown, gloves, and face mask should have been worn because the resident was under Enhanced Barrier Precaution, but the gown was not put on because that part was missed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen observation, a large leak was found in the ceiling area in front of the steam table and milk cooler, with water accumulating on the floor. This posed a potential contamination risk to food, equipment, and staff. Additionally, several ceiling-mounted air-conditioning vents were observed to have condensation dripping over critical areas such as the steam table, milk storage refrigerator, 3-compartment sink, juice dispenser, and dish machine room, all of which could lead to food and equipment contamination. Further issues were identified with the facility's dishwashing and sanitizing processes. A chemical test of the low-temperature commercial dish machine revealed no presence of sanitizing chemical in the final rinse, failing to meet the regulatory requirement of 50 PPM. Similarly, the 3-compartment sink's Quaternary chemical level was found to be over 300 PPM, exceeding the minimum requirement and posing a toxic risk. Additionally, a large pan of raw chicken was improperly thawed in warm water, and the reach-in refrigerator had a torn door gasket and rusted shelves. Cleaning cloths lacked the necessary sanitizing chemical, and numerous cooking pots and pans were covered in thick black carbon matter. During subsequent observations, the main kitchen's exhaust system was found to be rust-laden, and the plate warming lowerator was broken, with many resident entree plates stored within it being broken or chipped. The maintenance director was observed in the food production area without a beard/mustache guard. Food temperatures on the steam table were below the regulatory minimum, with pureed scrambled eggs and French toast recorded at 110 and 112 degrees F, respectively. Additionally, a diet aide was observed wrapping silverware unsanitarily, handling it by the eating stem, and placing it into bags without proper washing in the required 3-step process.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey on June 17, 2024. The dumpster located at the rear of the facility was overflowing, preventing the lids from closing. Broken bags of garbage and trash were observed within the open dumpster cavity and spilling onto the ground in front of the dumpster. Additionally, due to the overflowing dumpster, approximately 30 bags of trash, garbage, and nursing waste were stored on the ground about 10 feet from the dumpster. Many of these bags were ripped open, resulting in trash, garbage, and soiled PPE supplies, such as gloves and gowns, being scattered around the ground area. The facility's Administrator attributed the situation to recent flooding in the area, which delayed routine trash pick-up.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across multiple units. During the survey conducted from June 16 to June 17, 2024, numerous deficiencies were observed in Unit #1, Unit #2, and Unit #3. These included damaged walls, short privacy curtains, malfunctioning lights, and accumulation of yellow matter on bathroom faucets. Additionally, there were issues with room furnishings such as worn over-bed tables and damaged doors, which contributed to an uncomfortable living environment for the residents. In Unit #1, specific problems included privacy curtains that were too short to provide visual privacy, damaged room walls, and malfunctioning equipment such as over-bed lights and bathroom faucets. The community shower and beauty salon/dialysis storage room also had significant cleanliness issues, with rust-laden door frames and hair accumulation on the floor. The dialysis supplies were stored improperly, and the staff refrigerator was heavily soiled, indicating a lack of proper maintenance and sanitation practices. Unit #2 and Unit #3 exhibited similar issues, with strong urine odors, black mold-like matter in bathrooms, and broken or missing window treatments. The privacy curtains were consistently too short, failing to ensure resident privacy. The soiled utility room and nursing supply closet had additional maintenance concerns, such as rust-laden equipment and improperly stored supplies. The dining room and nurses' stations also showed signs of neglect, with stained floors and non-functional lighting. Despite the presence of maintenance logs at the nurses' stations, the maintenance staff failed to document and address these issues effectively.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to obtain and document an accurate code status for a resident, leading to a deficiency in honoring the resident's right to formulate an advance directive. The resident, who was admitted to the facility with multiple diagnoses including hypertension, diabetes mellitus, and idiopathic pulmonary hemosiderosis, did not have a documented code status in their electronic health record. This oversight was identified during a review of the resident's records and interviews with facility staff. Interviews with various staff members revealed a lack of clarity and communication regarding the responsibility for ensuring code status documentation. The Unit Manager was unaware of the missing code status, while the Assistant Social Worker indicated that the information is typically obtained from the family and the doctor. The Admissions Director stated that social services handle advanced directives, but there was no clear process for ensuring that code status orders are obtained and documented. The Director of Nursing acknowledged the issue, noting that a previous DON had left with several staff members, which may have contributed to the oversight.
Inaccurate Medical Personnel Title in Resident Records
Penalty
Summary
The facility failed to ensure the accuracy of medical personnel titles in the records for a resident. The issue was identified during a review of the records for a resident who was admitted with diagnoses including Disorganized Schizophrenia, Other Psychotic Disorder, and Major Depressive Disorder. The Minimum Data Set for the resident indicated a cognitive response. However, a discrepancy was found in the Physician's Note dated 12/28/2023, which was electronically signed by a Nurse Practitioner but identified as a physician in the Electronic Medical Records. Interviews with the Director of Nursing (DON) and the Admission Director revealed confusion over who was responsible for entering and verifying medical personnel titles in the facility's electronic system. The DON, who was new to the facility, initially believed the Admission Director was responsible for entering the information, while the Admission Director stated that the responsibility had shifted to the DON. This miscommunication led to the incorrect identification of the Nurse Practitioner as a physician in the resident's records.
Failure to Implement Care Plans for Bed Rails and Catheter
Penalty
Summary
The facility failed to develop and implement care plans for the use of bed rails for three residents and for a urinary catheter for one resident. The facility's policy on the proper use of bed rails, implemented in May 2023, requires ongoing monitoring and supervision, which should be documented in the resident's care plan. However, the facility did not have care plans for the use of bed rails for three residents, despite their documented need for them. Interviews with staff revealed confusion about responsibility for initiating these care plans, with the MDS Coordinator and Restorative Nurse both indicating that the other was responsible. Resident #54, who is moderately cognitively impaired, was observed using bed rails for mobility and positioning, but no care plan was in place. Similarly, Resident #5, who is cognitively intact, and Resident #120, who is moderately cognitively impaired, both had orders for bed rails but lacked corresponding care plans. Observations noted that the bed rails were covered with foam material, which was not part of the prescribed care. Staff interviews indicated a lack of clarity about the appropriate use of these rails and the materials used to cover them. Additionally, the facility failed to develop a care plan for Resident #7's indwelling urinary catheter. Despite having a procedure for catheter placement and orders for clinical monitoring, the care plan did not address the catheter or include strategies to prevent complications. The MDS nurse acknowledged that the care plan did not reflect the resident's current needs, highlighting a gap in the facility's documentation and care planning processes.
Failure to Apply Splints as Ordered for Resident
Penalty
Summary
The facility failed to apply splint devices as ordered for a resident, leading to a deficiency in maintaining and/or improving the resident's range of motion. The resident, who was moderately cognitively impaired, had bilateral impairments to upper and lower extremities and was dependent on staff for all activities of daily living. The resident's care plan included orders for daily application of knee and elbow splints for contracture prevention and management. However, observations over several days revealed that the resident was frequently without the prescribed splints or braces, both while in bed and in a wheelchair. Interviews with staff indicated a lack of consistent application of the splints. Staff members acknowledged the resident's contractures and the purpose of the splints to prevent further contraction. However, discrepancies were noted in the timing and duration of splint application, with reports of splints being removed prematurely or not applied at all. Additionally, there was no documentation of the resident not tolerating the devices or having them removed, despite staff acknowledging that the resident sometimes removed the splints herself. The Director of Nursing noted the absence of a restorative program prior to their arrival, which may have contributed to the oversight.
Failure to Document and Obtain Orders for Indwelling Catheter
Penalty
Summary
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 a resident with bladder incontinence. During an observation, it was noted that the resident had an indwelling catheter in place, which he stated was medically necessary. However, a review of the resident's records revealed no physician's orders for the catheter or documentation of catheter care interventions, despite the resident having a history of urinary tract infections and other related diagnoses. Interviews with facility staff, including LPNs and a CNA, confirmed that the resident had an indwelling catheter for several months, but there were no orders or documentation in the computer system regarding the catheter's care. The staff acknowledged that the resident returned from a urologist appointment with the catheter, but the necessary orders were not entered into the system. The Assistant Director of Nursing also confirmed the lack of documentation and orders for the catheter care. The facility's policy on the appropriate use of indwelling catheters requires that such devices be used only when clinically necessary and in accordance with physician orders. The policy also mandates appropriate treatment and services to prevent urinary tract infections. However, the facility did not adhere to these guidelines, as evidenced by the absence of physician orders and documentation for the resident's indwelling catheter care.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure timely physician visits for one resident, identified as Resident #32, as required by their policy. According to the facility's policy, a resident must be seen by a physician or a physician delegate at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter. However, a review of Resident #32's records revealed that the resident was not seen by the primary physician for the past six months. Instead, the resident was seen by a Nurse Practitioner (NP) on 12/28/2023, and subsequently by a Physician's Assistant (PA) on multiple occasions, with no visits from the primary physician during this period. Interviews conducted with the Director of Nursing (DON) and the Primary Care Physician (PCP) for Resident #32 highlighted a lack of coordination and oversight in ensuring timely physician visits. The DON acknowledged that it is her responsibility to ensure timely visits and that she runs a monthly report to track these visits. However, the PCP stated that the facility does not provide a list or schedule of patients to be seen, and his practice manages the scheduling independently. This lack of communication and oversight resulted in Resident #32 not being seen by the primary physician as required by the facility's policy.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to adequately monitor behaviors for residents receiving psychotropic medications, as evidenced by observations, interviews, and record reviews. For Resident #32, the facility did not document behaviors or symptoms related to the use of Risperdal for mood disorder associated with disorganized schizophrenia. Despite orders to monitor specific behaviors and side effects, the behavior monitoring record only showed check marks without indicating whether behaviors were observed. Staff interviews revealed confusion about documentation procedures, with staff acknowledging that they did not document pacing behavior because it was considered normal for the resident. Resident #34, who was on Venlafaxine for major depressive disorder, had multiple instances where behavior monitoring records indicated observed behaviors, yet no corresponding documentation was found in the nurse's progress notes or CNA tasks. This lack of documentation suggests a failure to properly monitor and record the resident's response to the medication, as required by the facility's policy. Similarly, Resident #96, who had severe cognitive impairment and was on Buspirone and Mirtazapine, had behavior monitoring records indicating observed behaviors without corresponding documentation in health status notes. The facility's failure to document and monitor behaviors and side effects for residents on psychotropic medications, as outlined in their care plans and physician's orders, highlights a significant deficiency in medication management and monitoring practices.
Medication Storage Deficiency
Penalty
Summary
The facility failed to secure medications at the bedside for one resident, as observed during a survey. The resident, who had been diagnosed with Parkinsonism and Major Depressive Disorder, was found to have eye drops on their nightstand, which were not stored in accordance with the facility's medication storage policy. The policy mandates that all medications be stored in locked compartments to ensure security and proper conditions. The eye drops observed were not labeled with the resident's name or room number, and there was confusion regarding whether they were the correct medication as per the physician's order. During interviews, the resident confirmed that staff administered the eye drops twice daily. However, the LPN responsible for the resident's care was unable to confirm if the eye drops at the bedside or those in the medication cart were the prescribed artificial tears. The LPN acknowledged the oversight and removed the eye drops from the nightstand. The consultant pharmacist confirmed that the eye drops found were not a substitute for the ordered artificial tears, indicating a discrepancy in medication administration and storage practices.
Failure to Provide Proper Pureed Diets
Penalty
Summary
The facility failed to provide food prepared in a pureed form as required for residents with physician-ordered pureed diets. During a breakfast meal observation, the pureed eggs were found to be lumpy and gritty, not meeting the smooth consistency required. The facility's Registered Dietitian confirmed the improper texture and advised against serving the eggs. The breakfast cook admitted to not taste-testing the pureed foods and had not received training on their preparation. Similarly, during a lunch meal observation, the pureed herb-crusted fish contained particles and was not smooth, as confirmed by both the dietitian and the surveyor. The facility's diet census indicated 14 residents required pureed diets, including two sampled residents with dysphagia and severe cognitive impairment. The facility's diet manual specified that pureed foods should have a smooth, pudding-like consistency, which was not achieved in these instances.
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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.
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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) |
|---|---|---|---|---|
| North Beach Healthcare And Rehabilitation Center | 0.2 mi | ★★★★★ | 11 | 0 |
| Aventura Rehab And Nursing Center | 1.4 mi | ★★★★★ | 8 | 0 |
| Regents Park At Aventura | 1.5 mi | ★★★★★ | 6 | 0 |
| The Lilac At Silver Palms | 1.5 mi | ★★★★★ | 13 | 0 |
| Vi At Aventura | 2 mi | ★★★★★ | 0 | 0 |
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