Every finding on record at Bay Breeze Rehabilitation by Harborview

Based on observation, interview, and record review, the facility failed to ensure that food preparation equipment was maintained in a clean and sanitary condition. All residents are able to eat, meaning the unsafe conditions had the potential to affect all residents in the facility.On 08/24/2026 at 11:34 AM, it was observed that two standard ovens and one double stacked oven contained visible buildup and residue accumulated on the interior surfaces. The interior bottom and side panels displayed dark discoloration and raised, textured debris. The facility's deep fryer contained dark brown, murky oil with visible brown sediment, and heavy buildup was noted along the fryer's interior sides.During this observation, an interview with Staff A, Head Cook. Staff A stated that the facility did not have any cleaning logs to demonstrate when the ovens and fryer were last cleaned. Staff A could not speak to when the ovens and the fryer were last cleaned.On 08/25/2026 at 1:13 PM, a follow up observation revealed that one of four ovens were cleaned, but the fryer remained dirty. An interview was completed with the Dietary Manager at this time, who provided a cleaning log, which had been started that same day. The Regional Director of Food Services was present and acknowledged the condition of the kitchen equipment and there were no cleaning logs prior to 08/25/2026 to demonstrate when kitchen equipment was last cleaned.On 08/26/2026 at 11:14 AM, a follow up interview with the Regional Director of Food Services was conducted. He stated the equipment should be cleaned weekly. He stated the staff have been educated on the new cleaning log responsibilities but did confirm that no cleaning logs had been maintained to demonstrate completion of this expectation prior to 08/25/2026. On 08/27/2026 at approximately 10:24 AM, the Administrator provided a performance improvement plan (PIP) dated 08/06/2026, which focused on recurring maintenance and physical plant deficiencies that impact resident safety, staff efficiency, regulatory compliance. During an interview, the Administrator stated that the roster of attendees for the initial PIP meeting did not include the Maintenance Director or any staff from the dietary department.On 08/27/2026 at approximately 11:00 AM, an interview was conducted with the Maintenance Director. He stated that he had not had any meetings with the kitchen staff regarding equipment maintenance and cleaning but reported that he would be conducting an in service with the staff as soon as possible.A review of the facility's Dietary Department Sanitation policy dated 2025 showed that the facility required a daily/weekly cleaning schedule posted each Sunday that associates must complete and sign off for assigned cleaning tasks, and incomplete tasks must be reported to the supervisor before the end of the shift.A review of the facility's Sanitation Inspection policy dated 03/01/2026 also states the facility must ensure equipment is maintained clean, sanitary, and compliant with applicable state and federal regulations. Inspection areas will be conducted but not limited to the following areas: main production area, food prep area, fryer and oven

Based on observations, staff interviews, review of the electronic medical record (EMR) and review of the facilities policies and procedures the facility failed to provide safe and secure storage of medications for 2 of 16 residents reviewed for medication storage. (Resident #72 and #84)The findings included:On 8/24/2026 at 11:00 AM, an observation was conducted of multiple over-the-counter medications stored at the bedside of Resident #72, including a bottle labeled Magnesium Glycinate, a bottle labeled Antacid Chews, a tube labeled Icy Hot cream, and a box labeled Lidocaine patches. (Photographic evidence obtained)On 8/24/2026 at 11:30 AM, an observation was conducted of medication at the bedside of Resident #84. The medication cup contained a thick, orange-colored liquid medication. During this observation, Resident #84 stated the medication had remained at her bedside throughout the morning and that she did not know what the medication was. (Photographic evidence obtained)A review of Resident #84's medication orders revealed an order for Lactulose oral solution 10 grams/15 milliliters by mouth once daily, and documentation that medication was given to Resident #84 on 8/24/2026 at 9:00 AM by Staff B, Licensed Practical Nurse (LPN).On 8/24/2026 at 1:00 PM, an interview was conducted with Staff B. Staff B stated Resident #84 was sleeping at the time she took the medications to them to administer but that she administered the medication when Resident #84 woke up. Staff B was also asked about the over-the-counter medications observed at Resident #72's bedside. Staff B stated that residents were not permitted to keep over-the counter medications at their bedside, and all medications Resident #72 had at the bedside had been removed. During this interview, it was observed that there were Lidocaine patches still in a box at Resident #72's bedside. Staff B informed Resident #72 that she would contact the physician to obtain an order for the medication.Per review of the facility's policy titled Administration of Drugs, it was noted that Should a drug be withheld, refuse, or given other than at the schedule time, the nurse should give the appropriate chart code inside Electronic Medication Administration Record (eMAR) that states the reason for not administering that particular drug.

Based on observations and staff interviews, the facility failed to maintain appropriate food handling and storage practices, as numerous food items across dry storage, refrigeration, and freezer areas were found unlabeled, undated, uncovered, or unsanitary. The findings include: During a kitchen tour conducted with the Registered Dietitian Nutritionist (RDN) on 04/01/2026 at approximately 10:04 AM, multiple deficiencies in food labeling, storage, and sanitation practices were observed: In the dry storage area, two opened bags of pasta, a gallon of red wine vinegar, a gallon of apple cider vinegar, an opened bag of rice, two cartons of dried mashed potatoes, and more than thirty opened spice containers lacked labels indicating when the items were opened.In the refrigerated section, three prepared sandwiches and three prepared salads were stored without preparation or open date labels, and a box of chocolate shakes had sticky residue on the exterior surface.In the freezer, a zip locked bag of meat was stored without any label identifying the contents or dates.Canned goods on the shelving had date markings that were not easily readable, preventing staff from determining product rotation or identifying older inventory.The RDN acknowledged ongoing issues with labeling and confirmed that undated prepared foods were being discarded. The facility currently has no permanent dietary manager, and the interim manager is absent due to illness.During an interview on 04/01/2026 at approximately 3:00 PM, the Administrator acknowledged the deficiencies identified by the RDN and provided documentation of education given to dietary staff on proper food labeling and storage procedures.A review of the facility's policy titled Food Storage stated that food storage areas shall be maintained in a clean, safe, and sanitary manner.

Based on interviews, record review, and policy review, the facility failed to ensure that 2 of 4 residents' family members was notified of a significant change in condition and subsequent transfer to the hospital, as required by facility policy and regulatory expectations. (Resident #2 and #4) During a 04/01/2026 interview at about 2:00 PM, Employee G (a Registered Nurse) stated that she completes the Situation Background, Assessment, Recommendation (SBAR) form and uses the communication book during any hospital transfer. However, she was unsure who is responsible for notifying the resident's representative about a change in condition, stating that she believed the supervisor handled those calls.During a chart review and interview on 04/01/2026 at approximately 3:45 PM with the Assistant Director of Nursing (ADON), it was stated that staff are expected to notify family of any change in status and document this in the SBAR Template and progress notes. However, 2 of the 4 sampled residents did not have documentation showing that family had been notified during a change in condition and transfer to the hospital. The records of Resident #4, who had a change of condition on 01/01/2026, and Resident #2, who had a change of condition on 02/18/2026, showed only that the residents themselves were notified, with no documentation indicating that they refused family notification. The ADON confirmed that required family notification was missing from both records.During an interview with the family of Resident #2 on 04/01/2026 at approximately 6:39 PM, she reported that the facility failed to notify them about lab results, tests, changes in condition, or the transfer and hospitalization that occurred on 02/18/2026. She stated that the family only learned of the situation when the hospital contacted them after Resident #2 was already in the Intensive Care Unit.On 04/02/2026 at about 9:08 AM, the Director of Nursing (DON) and the Administrator reported that they were not aware of the facility policy requiring notification of the resident's representative when there is a change in status or a transfer to the hospital. The DON explained that staff typically do not notify representatives if the resident is alert, oriented, and able to make decisions. They were informed of earlier chart reviews showing that representatives were not notified during changes in status for Resident #2 and #4.On 04/01/2026, a review of the facility's Change of Condition policy (reviewed June 2025) requires the Nurse Supervisor to notify the resident's representative whenever the resident experiences an accident or incident resulting in injury, any significant change in physical, mental, or psychosocial status, a room change, a discharge, or the need for hospital transfer-unless the resident has specifically requested otherwise.

Based on observations, record reviews and interviews, the facility failed to follow the plan of care for 1 of 2 residents sampled for pressure injuries. (Resident #36) The findings include: On 5/19/25, Resident #36 was observed lying in bed. There was no low air loss mattress in use. Further observations on 5/20/25 at 1:24 PM and 3:32 PM as well as on 5/21/25 at 8:45 AM and again at 11:40 AM revealed Resident #36 lying in bed with no low air loss mattress in use. On 5/20/25, a record review was conducted for Resident #36. The care plan, revised last on 7/1/24, contained skin impairment interventions which included the use of a low air loss mattress. (photographic evidence obtained). A review of the orders showed no physician orders for a low air loss mattress. On 05/21/25 at 09:49 AM, an interview with the Director of Nursing (DON) was conducted. The DON was asked who is responsible for ensuring care plans are implemented. The DON stated that Minimum Data Set nurses and clinical managers follow up on this. The DON stated the resident had been on a low air loss mattress but it was removed for cleaning and has not been placed back on the bed yet and acknowledged it was not on the bed at this time. On 5/21/25 at 10:01 AM, the Central Supply staff checked the mattress and stated it was a regular mattress.

Based on observations and interviews, the facility failed to maintain 2 of 3 garbage dumpsters located behind the facility for waste managment. The findings include: On 5/19/2025 at approximately 10:40 AM, an observation was made of the 3 dumpsters located to the rear of the facility. This observation revealed that dumpster #1 was without a door on the side to secure the waste located inside the dumpster, which could lead to pests having access to the waste. Dumpster #3 was noted to have a rusted hole area to the right lower front corner. (Photographic evidence obtained) The Registered Dietician was interviewed during these observations. She indicated that she was unaware of how long the dumpsters had been in this condition. On 5/19/25 at approximately 10:58 AM, an interview was conducted with the Administrator, who indicated that she noted the door missing off the garbage dumpster last summer and had contacted the waste managment company, whom she did not get a reply from. The Administrator indicated that she would contact the waste management company to have the dumpsters replaced.

Based on observations, interview and record review, the facility failed to maintain infection control practice for 1 of 4 residents observed during medication administration observations. (Resident #60) The findings include: On 2/29/24 at approximately 9:17 am, an observation was made of medication administration to Resident #60 by Nurse B, a Licensed Practical Nurse. Nurse B entered the room to administer medications but did not place a barrier between the medication inhaler for Budesonide-Formoterol Fumarate Aerosol 165-4.5 micrograms (MCG), (a sterodial inhaled medication used to control Chronic obstructive pulmonary disease) and the resident's over the bed table. After the medication was administered, Nurse B returned the inhaler to the medication cart. On 2/29/24 at approximately 9:20 am, an interview was conducted with Nurse B, who indicated that she did not place a barrier between the inhaler and the over the bed table. Nurse B acknowledged that this was an infection control issue. On 2/29/24 at approximately 10:00 am, an interview was conducted with the Director of Clinical Services, who stated his expectation was for the nurse to place a barrier between medications and the over the bed table for infection control. A review of the facility policy titled Administration of Drugs, dated October 2019, indicated, Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director . Policy Interpretation and Implementation: 18. Ensure all infection control practices are followed during the administration of medications (i.e.: using a barrier for multidose medications, cleaning of equipment/tools between residents, hand hygiene, exterior handling of containers, etc.).

Based on observations and interviews, the facility failed to maintain linens in good condition. The findings include: On 02/26/24 at approximately 2:17 PM, Resident #218 was observed with a large hole in the linens as the resident was resting in bed (photo evidence obtained). When asked abouth this, Resident #218 stated that the staff had recently changed her linens. On 02/27/24 at approximately 1:07 PM, Resident #218 was observed in bed eating lunch. During this observation, it wass noted that the bottom sheet had a large hole in the upper corner. In an interview on 02/28/24 at approximately 8:31 AM, Staff D, a Certified Nusing Assistant, was asked what is their process if they find sheets that are ripped or have holes. She stated that the facility is supposed to throw those out, so she sets it aside and sends it back to laundry. On 02/28/24 at approximately 11:40 AM, a clean bottom fitted sheet was pulled from two different clean linen carts down the 400 hallway. Both sheets were observed to have large holes in the corners. (photo evidence obtained) On 02/28/24 at approximately 11:45 AM in an interview, the Director of Nursing stated they are always checking linen and she was surprised that they had any with holes. On 02/28/24 at approximately 11:52 AM, the Administrator confirmed in an interview that they should not have linens with holes on the beds and they will be completing an overall inventory.

Based on observation, interview, and policy review, the facility failed to secure medications for 1 of 8 residents reviewed. (Resident #54). The findings include: On 2/27/24, an observation was made of Resident #54's room. The resident was lying on their right side, facing away from the door, with a cup of unidentified medications sitting on the residents over the bed table in a medication administration cup. Resident #54 stated the nurse just left them there. (Photographic evidence obtained) On 2/27/24 at approximately 10:25 am, an interview was conducted with Nurse A, a Licensed Practical Nurse, who confirmed the medications on the over the bed table were Resident #54's morning medications. Nurse A stated she left the medications because she needed to get the resident a protein drink and bring it back to the resident. Nurse A went on to state that she was trying to finish up another resident's medications then she was coming back to Resident #54. Nurse A confirmed she should not leave the medications on the over the bed table and should stay with the resident while they took their medications. On 2/27/24 at approximately 10:30 am, an interview was conducted with the Director of Nursing, who indicated her expectation of nurses to stay with the residents and watch them take their medications and to not leave them on the over the bed table. Review of facility policy titled Administration of Drugs, dated October 2019, stated Policy: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. Under Policy Interpretation and Implementation: 8. Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled. 9. The nurse administering the drug must record such information on the resident's EMAR before administering the next resident's drugs.

Based on observations, interview, record review, and review of the facility policy, the facility failed to ensure staff who were not up-to-date with all recommended COVID-19 vaccine doses took precautions to mitigate the transmission and spread of COVID-19. The facility failed to ensure employees who were not up-to-date with all recommended COVID-19 vaccine doses, wore the required Personal Protective Equipment (PPE) which included Niosh 95 (N95) mask. This failure had the potential to affect all residents and staff in the facility. Findings include: Review of the facility's policy titled, COVID-19 Vaccine Mandate for Staff, dated 02/04/22, revealed .ACCOMODATIONS FOR UNVACCINATED STAFF: Unvaccinated staff members with approved exemptions or approval for delays must wear a facemask .Unvaccinated staff members with exemptions or approvals for delay in vaccination must continue wearing facemasks if the COVID infection control guidelines requiring masks use are removed. Review of the facility's policy titled, Coronavirus (COVID-19) Precaution Plan, dated 04/08/22 revealed, Policy: The Center COVID-19 Response Team has been activated and will utilize this COVID-19 guidance to minimize I [sic] prevent an outbreak in the Center for the duration of the COVID-19 pandemic .PERSONAL PROTECTIVE EQUIPMENT (PPE) .Universal use of face masks by center personnel while in the center: Health Care Providers (direct patient care I [sic] non-direct patient care) - wear surgical masks . During an observation and interview on 04/25/22 at 9:34 AM, Registered Nurse (RN) 1 was at the 300/400 hall nurses' station wearing a surgical mask. RN1 stated she was not vaccinated and had an approved religious exemption. RN1 also stated she had been educated by the facility that she only had to wear a surgical mask while she was in the facility unless she was going into a COVID-19 transmission-based precaution (TBP) room. Review of RN1's Request for Religious Exemption from COVID-19 Vaccination form dated 11/16/21 revealed RN1 applied for an exemption based on religious beliefs. The facility's Human Resource Director (HRD) approved the exemption request on 11/23/21. During an observation and interview on 04/25/22 at 9:41 AM, Certified Nurse Aide (CNA) 2 was at the 300/400 hall nurses' station wearing a surgical mask. CNA2 stated she was not vaccinated and that she was religiously exempted from getting the COVID-19 vaccination. CNA2 stated due to her exemption she had to have a COVID-19 test weekly and wear a surgical mask. Review of CNA2's Request for Religious Exemption from COVID-19 Vaccination form dated 11/15/21 revealed the CNA had applied for a religious exemption. The facility's HRD approved the exemption request on 11/30/21. During an observation and interview on 04/25/22 at 9:44 AM, Housekeeper (HK) 3 was sweeping the floor on the 100-hall wearing only a surgical mask. HK3 stated she had a religious exemption from the COVID-19 vaccination and was told she only had to wear a surgical mask while she was in the building unless there was a COVID-19 positive room she had to enter. Review of HK3's Request for Religious Exemption from COVID-19 Vaccination form dated 11/17/21 revealed HK3 had applied for a religious exemption from the COVID-19 vaccination. The facility's HRD approved the exemption request on 11/30/21. During an observation and interview on 04/25/22 at 9:47 AM, Licensed Practical Nurse (LPN) 4 was on the 200-hall at the medication cart wearing only a surgical mask. LPN4 stated she was religiously expected from the COVID-19 vaccination and was told by the facility she had to wear a surgical mask while in the building. Review of LPN4's Request for Religious Exemption from COVID-19 Vaccination form dated 11/18/21 revealed LPN4 had applied for a religious exemption from the COVID-19 vaccination. The facility's HRD approved the exemption request on 11/23/21. Interview on 04/25/22 at 2:16 PM with the facility's Regional Nurse Consultant (RNC) revealed it was his expectation that staff who were exempted from the COVID-19 vaccination would wear a surgical mask while they were in the facility, unless the staff member was going into a TBP room that required a higher-level mask. The RNC stated that the Florida State Survey Agency (SSA) informed the facility that surgical masks were acceptable for the exempted staff. The RNC also stated that the facility mitigates the spread of COVID-19 by mandating the exempted staff to be tested at a minimum of weekly whenever the county transmission rate was above Low. The RNC verified the exempted staff observed by the surveyor were wearing only surgical masks. A request was made for the documentation of the Florida State Survey Agency regarding the requirement of only a surgical mask and was not provided before exit of the survey. During an interview on 04/25/22 at 2:19 PM, the Director of Nursing/Infection Preventionist (DON/IP) stated it was her expectation staff who were exempted from the COVID-19 vaccination would wear surgical mask while in the building per the facility's policy. During an interview on 04/25/22 at 2:21 PM, the Administrator stated it was his expectation COVID-19 vaccination exempted staff wear surgical masks at all times while in the facility.

Based on observation, staff interviews, and resident interview the facility failed to provide housekeeping and maintenance services to maintain a clean, sanitary, and homelike environment for 3 of 68 resident rooms observed during the survey. (rooms 213, 215, and 219) The findings include: On 7/12/21 at approximately 11:53 AM, in room 215's restroom was observed one unlabeled, not bagged bedpan and one unlabeled, not bagged graduate container sitting in the restroom floor. On 7/12/21 at approximatley 11:59 AM, in room 219 B, a dusty suction machine was observed sitting on top of the over bed table and 2 apple sized holes were noted in the closet's laminate near the sink. On 7/12/21 at approximately 12:55 PM, in room 213 A, torn, damaged sheetrock was noted on the wall near the restroom door, the bedside chest was damaged and had rough edges. Also observed were tissues and debris under the bed, and there was a dark area around the front of the sink. On 7/13/21 at approximatley 9:22 AM, in room 215 A, tissues were observed under the bed on the floor. On 7/14/21 at approximately 3:04 PM, in room 213 A, there was noted a loose cove base near the sink and a black dirt build up was noted in the shower. Room 215 A and B, the bedside chests were observed with damaged and rough edges. Observations of the bedside commode in room 213 B were conducted on 7/13/21 at 4:12 PM and 7/15/21 at 8:46 AM. The bedside commode contained a large amount of yellow liquid and tissue during both observations. Photographic evidence obtained. A tour of rooms 215/213 shared restroom and room 219 was conducted with the Director of Nursing (DON) on 7/14/21 at approximately 1:15 PM. The DON observed the bedpan and graduate container in the floor of 213/215 restroom and stated the items should be labeled with name and room number and stored in a bag in the dresser. She observed the suction machine in room 219 and stated it was nasty and dusty. She did not know how long the suction machine had been in the room. A tour of rooms 213, 215 and 219 was conducted with the maintenance director on 7/14/21 at approximately 3:04 PM. He observed and confirmed the damaged sheetrock, loose cove base, and damaged bedside chest in room 213. He stated the bedside chest needed to be replaced. He entered room 213 restroom and confirmed the dirt build up in the shower grout. He stated it was not sanitary. He confirmed the bedside chest perimeter was damaged in room 215 for both A and B beds. He observed the tissues under the bed in room 213 A. He stated housekeeping should be cleaning under the beds. He confirmed the 2 holes on the closet laminate in room 219 and stated he did not know what happened. An interview was conducted with resident #64 on 7/13/21 at approximately 4:12 PM. Resident #64 stated the staff had not emptied the bedside commode since around 5:00 AM.

Based on observation, staff interview and policy review, the facility failed to ensure all staff utilized proper hand hygiene while serving meal trays to 2 of 3 residents observed during meal service (#15, #79). The findings include: During lunch meal pass an observation of Staff A, a Certified Nursing Assistant (CNA) was conducted on 7/13/2021 at approximately 1:02 PM. Staff A, a CNA, was observed placing the lunch tray on resident #79 overbed table. Staff A, then placed a towel across resident # 79 chest, and shoulders. Staff A, CNA, was then observed removing a tray from the food service cart, and then placed the lunch tray on the overbed table for resident #15. Staff A was observed cutting resident #15 food with the utensils on resident #15 tray. Staff A was then observed removing a straw from the medication cart, paper was removed from the straw and the straw was placed in resident #15 beverage. Staff A, CNA, failed to sanitize her hands after serving resident #79 and before serving resident #15. An interview was conducted on 7/13/21 at approximately 1:40 PM, with staff A. Staff A, confirmed she did not sanitize or wash her hands between each resident while passing lunch trays. An interview was conducted with the DON on 7/14/2021 at approximately 12:25 PM, who confirmed her expectation is that all staff should either wash hands or use hand sanitizer between residents when serving meal trays. A review of the hand hygiene policy dated 5/12/21 revealed under section number 1: All personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. Section number 2: Associates must perform appropriate handwashing procedures under the following conditions: e. Between passing out meal trays.

Based on record review, staff interview and policy review the facility failed to maintain complete documentation of resident care for 2 of 24 sampled residents. (residents 53 and 76) The findings include: Review of resident #53's electronic record revealed the nurse practitioner inserted a urinary catheter for resident #53 on 7/9/21. The record revealed no orders or documentation for catheter care from 7/9/21 through 7/12/21. One entry of catheter care was documented on 7/13/21. The catheter was discontinued on 7/13/21. An interview was conducted with the Director of Nursing (DON) on 7/14/21 at approximately 9:28 AM. The DON reviewed resident #53's record and confirmed no catheter care was documented from 7/9/21 through 7/12/21 and the catheter had been placed on 7/9/21. She stated the expectation is catheter care should be documented every shift. Review of the facility policy for Charting (November 2001) reveals services provided to the resident are recorded in the resident's medical record. Medications given, services performed, etc. are recorded in the resident's chart. Entries must be recorded by the person rendering the service.

Based on interview and record review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman and failed to give the resident at least a 30 day notice of discharge for 1 of 3 (#1) residents sampled for discharge. The findings were: A review of an incident from 9/12/2018 revealed that Resident #1 was accused by another resident in the facility of speaking to her in a vulgar manner often. She stated that one day in the day room Resident #1 touched her breast and squeezed it and told her he would like to eat her private parts. She also stated that he had pulled his penis out and masturbated in front of her. This was reported to local law enforcement. On 10/5/2018, about three weeks later, local law enforcement arrived at the facility and took Resident #1 into custody for indecent exposure and battery. A review of the immediate discharge notice provided to the resident and wife was reviewed. It was dated 10/5/2018 and effective 10/5/2018. The reason given for the discharge was the safety of other individuals in this facility is endangered. Under the brief explanation section it stated, charges of battery, indecent exposure on 10/5/2018. A review of the resident's clinical record was conducted for the documentation and rationale for the immediate discharge. Review of physician, ARNP (advanced registered nurse practitioner) and psychiatry notes from admission until discharge found no entry in the medical record indicating the resident presented a danger or was in need of a discharge, much less an immediate discharge. Resident #1 had been admitted on [DATE] and a partial list of [DIAGNOSES REDACTED]. No other incidents similar to the incident of 9/12/2018 were documented. A review of the corresponding case number (not mentioned here for purposes of privacy) revealed that all charges were dropped against Resident #1 on 11/8/2018. On 3/13/2019 at 9:49am an interview was conducted with the Regional Ombudsman Manager. At that time he stated that the facility never sent over a copy of the discharge notice for Resident #1. He stated that he had to obtain it from the resident's wife. On 3/13/2019 at 2:58pm an interview with the administrator was conducted in which he stated that the resident has not been back to the facility since his arrest. He stated that the resident's discharge was effective immediately due to his belief that the resident posed a risk to other resident's in the facility. He and the Regional Nurse Consultant acknowledged that the Office of Appeal Hearings, Department of Children and Families disagreed with their assessment and for that reason they were appealing that decision.

Based on interview and record review, the facility failed to allow a resident to remain in the facility while exercising their right to appeal a discharge and failed to ensure a physician documented the need for immediate discharge due to behavioral status for 1 of 3 (#1) residents sampled for discharge. The findings were: A review of an incident from 9/12/2018 revealed that Resident #1 was accused by another resident in the facility of speaking to her in a vulgar manner often. She stated that one day in the day room, Resident #1 touched her breast and squeezed it and told her he would like to eat her private parts. She also stated that he had pulled his penis out and masturbated in front of her. This was reported to local law enforcement. On 10/5/2018, about three weeks later, local law enforcement arrived at the facility to take Resident #1 into custody for indecent exposure and battery. He was taken to jail at that time. A review of the corresponding case number (not mentioned here for purposes of privacy) revealed that all charges were dropped against Resident #1 on 11/8/2018. A review of the facility's discharge notice, issued to the resident and his wife, was reviewed. It was dated 10/5/2018 and effective 10/5/2018. The reason given for the immediate discharge was the safety of other individuals in this facility is endangered. Under the brief explanation section it stated, charges of battery, indecent exposure on 10/5/2018. A review of the resident's clinical record was conducted for the documentation and rationale for the immediate discharge. No other incidents similar to the incident of 9/12/2018 were documented. Resident #1 had been admitted on [DATE] and a partial list of [DIAGNOSES REDACTED]. Review of physician, ARNP (advanced registered nurse practitioner) and psychiatry notes from admission until discharge found no entry in the medical record indicating the resident presented a danger or was in need of a discharge, much less an immediate discharge. On 10/4/2018, the day before discharge, the ARNP documented a follow-up on chronic medical conditions and [MEDICAL CONDITION]. The ARNP documented that resident #1 was calm and cooperative and stated, I'm doing fine and that the resident had mild dyspnea (difficulty breathing) with conversation. On 9/20/2018 the ARNP documented that resident #1 was easily upset and agitated when discussing discharge. There was no mention on the ARNP's note to indicate why discharge was being discussed with Resident #1 at that time; however, there was a nursing note, dated 9/15/18, that stated Resident #1 was overheard telling his sitter that his wife [MEDICAL CONDITION] and he couldn't help her because he was at the facility. The ARNP noted the MMSE (mini-mental state examination) test showed severe cognitive impairment. The recommended plan in the psychiatry notes of 9/5/2018, 9/19/2018 and 9/26/2018 all included recommendations to watch for potential changes in mood or behavior and medication side effects. There were no discharge recommendations from psychiatry. Social Services notes were reviewed. On 8/22/2018, social services documented the completion of a standardized mini-mental state examination which scored a 16 out of 30, which indicates severe cognitive impairment. On 8/27/2018 social services documented that resident #1 was calm and cooperative and that discharge is not feasible. A review of nurses notes from admission in (MONTH) (YEAR) to discharge in (MONTH) found entries on 6/13/2018 and 9/16/2018 regarding sexually inappropriate comments directed toward staff, and an entry on 9/12/2018 regarding being flirtatious with staff. No other nursing entries regarding inappropriate behavior were identified. Minimum Data Set Assessment (MDS) dated the day of discharge, 10/5/2018 under Section E for Behavior documents behavior not exhibited for both A. Physical behavioral symptoms directed toward others (example abusing others sexually) and C. Other behavioral symptoms not directed toward others (example - symptoms such as . public sexual acts, disrobing in public .). The admission MDS dated [DATE] and the Quarterly MDS dated [DATE] also recorded, behavior not exhibited in Section E for Behavior. Resident #1's wife filed an appeal of the discharge with the department of Children and Families on 10/15/2018. On 1/28/2019 a final order was filed by the Office of Appeal Hearings with the Department of Children and Families. The final order stated, Based on the foregoing findings of fact and Conclusions of Law, the petitioner's appeal is GRANTED. The facility erred when it discharged the petitioner for being a danger to others in the facility. The facility is ordered to reverse its decision and allow the petitioner to return to the facility when the next bed is available. The facility provided a copy of their appeal to the above decision which was filed on 2/26/2019 (29 days after the final order from the Department of Children and Families). The resident was not readmitted back into the facility pending the appeal. On 3/13/2019 at 9:49am, an interview was conducted with the Regional Ombudsman Manager. The Ombudsman stated that Bay Breeze Senior Living refused to readmit Resident #1 when he was released from jail. On 2/20/2019 the Ombudsman visited the facility and requested for the resident to be readmitted to the facility in compliance with the Final Order of the fair hearing. The Ombudsman stated, to date, 3/13/2019, Resident #1 has not been readmitted to the facility. The resident is currently at home with his wife who is having difficulty caring for him due to her own health issues. On 3/13/2019 at 2:58pm, an interview with the administrator was conducted in which he stated that the resident has not been back to the facility since his arrest. He was asked why the resident had not been admitted back to the facility after the order was made to do so. He stated that the facility had appealed the decision. He was then asked if the facility was able to obtain a stay of the original order (which would allow them to wait to readmit the resident) and he stated that it was his understanding that filing the appeal itself served as a stay of the original order. He was asked to produce evidence that this was the case and was unable to do so during the course of the survey. On 3/15/2019 at 1:45pm, an interview was conducted with the clerk for the first district court of appeal. At that time she stated that filing an appeal does not stay the original order. She further stated that the facility had filed a stay for the original order; however, that had not been processed or acted on. She stated that the original order was currently in force and the facility would be in violation of the original order by not allowing the resident back in the facility.

Based on staff interview and record review, the facility failed to release requested administrative records to the Regional Ombudsman Manager for 1 of 3 (#1) residents sampled for discharge. The findings were: On 3/13/2019 at 9:49am an interview was conducted with the Regional Ombudsman Manager. At that time he stated that he went to the facility on [DATE] and after making a walking round requested a copy of the daily census report. He stated that he was told by the administrator that his legal counsel advised against releasing documents. After speaking to the administrator's legal counsel the Regional Ombudsman Manager left the facility without the requested documents. He stated that as of 3/13/2019 he had still not received the requested information. He went on further to state that 45 Code of Federal Regulations (CFR) 1324.11 (e)(2)(vii) gives him the right to request the above document. A review of 45 CFR 1324.11 (e)(2)(vii) revealed the following: Reaffirmation that the Health Insurance Portability and Accountability Act of 1996 (HIPPA) Privacy Rule, 45 CFR part 160 and 45 CFR part 164, subparts A and E, does not preclude release by covered entities of resident private health information or other resident identifying information to the Ombudsman program, including but not limited to residents' medical, social, or other records, a list of resident names and room numbers, or information collected in the course of a State or Federal survey or inspection process. On 3/13/2019 at 2:58pm an interview was conducted with the facility administrator and the regional nurse liaison. When asked they stated that the day the Ombudsman came out his conduct was out of line and that was why they asked him to leave without further information. They stated that he was given the option to request the information from their legal counsel and it could be emailed to the Ombudsman. When asked directly the administrator said that as of 3/13/2019 he did not believe that information had been given to the Ombudsman.

Based on interview and record review, the facility failed to ensure all ordered as needed (PRN) [MEDICAL CONDITION] medications were limited to 14 days or had a specific end date indicated by the prescriber for 1 or 5 residents (#66) sampled for unnecessary medications. The findings were: Review of the medical record for Resident #66 revealed a physician order, written 10/15/2018, for [MEDICATION NAME] (an anxiety medication) 0.5milligrams (mg) by mouth every 6 hours as needed for agitation. No 14 day limitation or end date was observed on the order. Further review of the medical record revealed a pharmacy recommendation, dated 11/9/2018, which recommended dicontinuation of the [MEDICATION NAME], but stated that if the as needed [MEDICATION NAME] could not be discontinued, current regulations required that the prescriber document the intended duration of therapy and the rationale for the extended time period. The physician failed to follow-up on the as needed [MEDICATION NAME] order. On 01/09/19 at 10:31am, an interview was conducted with the Director of Nursing who confirmed the order for the as needed [MEDICATION NAME] for resident #66 did not have an end date.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen environment for 3 of 3 observations conducted of the facility kitchen. The findings are: An initial kitchen tour was completed on October 23, 2017 at approximately 11:00 a.m. During the tour, the inside of the ice machine was observed to have a black/grey build-up in the upper right of the inside of the machine. The kitchen microwave had fingerprint smudges and grime on the outside, and the kitchen's oven had a significant amount of grease build-up on the sides and down the front. There were also six storage trays, where clean dishes were held, that were observed to be grimy on the bottom and on the sides, and there were mounted fans observed blowing toward the ice machine and coffee containers that were dusty. A second kitchen tour was conducted on October 25, 2017 at approximately 4:00 p.m, after the kitchen was recently cleaned according to the Kitchen Services Director. During this second tour, the oven was observed to have had a significant amount of grease on the inside and outside, and the left side of the oven had white debris and grease build-up observed. The kitchen's microwave was observed to have food splatter on the top of the inside, and there was sugar observed on the counter where it had spilled over to the sides of its container. There was also a white streaked film on all of the countertop surfaces, including the food prep area. The six storage trays, where clean dishes were held, were still observed to be grimy on the bottom and the sides. In the cafe area that is directly located on the outside of the kitchen there was a liquid egg looking substance in the drip pan for the waffle iron, and the waffle iron had visible grease and a crusty substance entirely covering the device. A third kitchen tour was conducted on October 25, 2017 at 4:20 p.m. Three staff were observed preparing trays for dinner and one staff was observed sweeping in the cook's area. There was a rack containing approximately seven uncovered food trays next to the male staff member who was sweeping (obtained photo evidence). An interview was conducted with Food Services Director on October 25, 2017 at 4:00p.m. The food services director was asked when the last time the microwave was cleaned, and stated just now. He was then asked if it appeared clean, and stated no, not really. He was also asked how often the oven got cleaned, and stated every night. He was asked if it looked like the oven had been cleaned the previous night, and stated no, not really. I will get on that right now. When asked how often the storage trays, where clean dishes were stored, were cleaned, he stated every three to six months. He was asked the last time they had been cleaned, nd replied three months ago.

Based on record review and staff interview, the facility failed to provide resident care and services in accordance with the resident care plan by failing to monitor behavior and side effects of medications for 1 of 5 sampled residents (#43). The findings are: Review of the medical record for resident #43 showed that he had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing notes showed that resident #43 had several episodes of inappropriate behavior, including yelling and cursing at staff, refusing care and being combative during care, and refusing medications due to delusions that nurses were poisoning him. On 10/3/17 the nurse documented that resident #43 was yelling at staff and accusing the nurse of trying to poison him. Later that same day, resident #43 was discovered trying to pull another resident out of their chair. The note stated that when the nurse attempted to intervene on behalf of the other resident, resident #43 attempted to strike the nurse and the other resident. Resident #43 then reached out and grabbed the nurse by the fingers and pulled the nurse's arm towards him and twisted her left wrist and arm. Two other staff members intervened at that time, and resident #43 attempted to strike other staff and screamed obscenities at them. The physician was called and notified of the resident's violent behavior, agitation and mistreatment of [REDACTED]. The physician also ordered a psychological evaluation for reduction of assaultive and inappropriate behaviors, reduction or stabilization of disorganized and confused thinking, stabilization of anxious mood, reduction of sexually inappropriate behaviors, and psychiatric medication management. On 10/4/17 a psychiatric evaluation was completed for resident #43. The recommendations after evaluation included to continue resident #43 on the [MEDICATION NAME] 5mg by mouth twice daily and add [MEDICATION NAME], an antidepressant, 5mg by mouth twice daily and start [MEDICATION NAME], an antianxiety medication, 5mg daily. Review of the plan of care for resident #43 showed that he was care planned for a potential for adverse side effects related to the use of antianxiety and antidepressant medications. The goal of the care plan indicated the desire for the resident to have no adverse effects during the next 90 days. Interventions listed to achieve this goal included to monitor the resident's behaviors per the behavior flow sheet and to observe for side effects of the medications. Further review of the resident's medical record showed no documentation related to behavior or medication side effect monitoring. The resident did not have a behavior monitoring sheet as indicated by the plan of care. An interview was conducted with the Assistant Director of Nursing (ADON), on 10/25/17 at 2:08 p.m. She confirmed that the facility uses behavioral monitoring forms to document and track resident behaviors and stated that residents receiving antipsychotics or antianxiety medications should have a behavioral monitoring form. After checking the resident's electronic chart, the ADON confirmed that there was no documentation of behavioral monitoring.

Based on record review and interview, the facility failed to provide services listed in the resident's plan of care by failing to have a nutritional assessment completed for 1 of 3 resident's reviewed for significant weight loss (#121). The findings include: Review of the medical record for resident # 121 showed the resident had experienced an 11.4% weight loss from April 8, 2017 to October 8, 2017, with an average meal intake between 51% and 100%. A review of the resident's nutritional care plan indicated the facility would obtain weights as ordered, notify the Physician or Advanced Registered Nurse Practitioner if significant weight loss occurred, and have the Registered Dietician (RD) to evaluate as needed. There was no documentation in the resident's record to support that the RD had been made aware of the resident's 11.4% significant weight loss. Resident #121 had last been assessed by the RD on May 12, 2017, prior to the significant weight loss. The RD was interviewed on 10/25/17 at 3:50 p.m., and was asked to describe the facility process for obtaining resident weights and notifying her of significant changes in resident nutritional status. The RD stated the resident weights were entered electronically by facility staff, and the system would alert her to any significant weight loss or weight gain for the residents. The RD stated she was aware of the significant weight loss for resident #121, but the loss had been gradual. She confirmed that she had not reassessed resident #121 since the significant weight loss had been identified, and confirmed that resident #121 was not on any nutritional supplements.