Inspection Report Summary
The most recent inspection on September 21, 2024, identified multiple deficiencies related to sanitation, medication administration, infection control, and resident care. Earlier inspections showed a pattern of issues involving medication errors, discharge planning, assistance with daily living activities, food service, and infection control. Inspectors cited recurring problems with medication management, sanitary conditions, and quality assurance processes. Complaint investigations found some substantiated issues, including failure to provide timely pain management and proper discharge planning, while most other complaints were unsubstantiated. The facility’s inspection history reflects ongoing challenges with compliance in several care and operational areas without a clear trend of improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 12
Date: Sep 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication administration, and facility maintenance.
Findings
The facility was found deficient in multiple areas including sanitary maintenance of resident rooms, updating PASRR assessments, pressure ulcer care, orthotic device application, enteral nutrition administration, medication administration errors, medication storage, dental services provision, food safety, and infection control practices.
Deficiencies (12)
Failure to maintain two resident rooms in a sanitary manner with stained walls, ceilings, floors, and privacy curtains.
Failure to update PASRR assessments to include current diagnoses for eight residents.
Failure to ensure timely identification and appropriate care of a facility-acquired pressure ulcer for one resident.
Failure to provide appropriate assistance with orthotic devices for one resident.
Failure to provide enteral nutrition per physician orders for three residents with gastrostomy tubes.
Failure to ensure post dialysis assessment was completed for one resident.
Failure to ensure nurses and nurse aides have appropriate competencies to care for residents.
Failure to ensure medications were stored safely, securely, and inaccessible to unauthorized persons for four residents.
Failure to ensure physician was promptly notified of a positive lab result for infection for one resident.
Failure to ensure dental services were provided for one resident.
Failure to procure, store, prepare, distribute and serve food in accordance with professional standards including proper labeling, glove use, and cleanliness in the kitchen.
Failure to maintain an effective infection control program including proper use of PPE, hand hygiene, and isolation precautions.
Report Facts
Residents sampled: 53
Residents sampled: 6
Residents sampled: 5
Residents sampled: 8
Residents sampled: 5
Hours: 15
mL: 900
mL: 885
mL: 115
mL: 23
mL: 1000
Degrees: 45
Days: 3
mg: 500
mg: 250
mg: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Identified loose tablets on floor and discussed medication crushing and administration |
| Staff B | Registered Nurse/Unit Manager | Provided dialysis communication binder and discussed post dialysis assessments |
| Staff D | Licensed Practical Nurse | Discussed enteral nutrition oversight and medication administration error |
| Staff E | Licensed Practical Nurse/Unit Manager | Observed medication administration and discussed infection control and hand hygiene |
| Staff F | Licensed Practical Nurse/Unit Manager | Discussed enteral nutrition oversight and medication administration error |
| Staff G | Certified Nursing Assistant | Reported on splint application and enteral nutrition knowledge |
| Staff I | Restorative Nursing Assistant | Reported finding splints off and applying splints |
| Staff K | Registered Nurse | Discussed delay in enteral feeding start for Resident #101 |
| Staff N | Nurse Practitioner | Discussed enteral feeding order decisions for Resident #14 |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care deficiencies and oversight |
| Director of Infection and Control | Director of Infection Prevention and Control | Confirmed positive culture findings and discussed infection control |
| Social Services Assistant | Observed not wearing PPE while assisting resident on contact precautions | |
| Certified Dietary Manager | Certified Dietary Manager | Discussed kitchen food safety and glove use |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 21, 2024
Visit Reason
The inspection was conducted to assess the sanitary conditions and maintenance of resident rooms in the facility, specifically focusing on cleanliness and the environment's safety and comfort.
Findings
The facility failed to maintain two resident rooms in a sanitary manner, with observations of stained walls, ceilings, floors, and privacy curtains, presence of debris and insects, and loose bathroom tiles. Interviews revealed housekeeping and maintenance issues, including non-compliance by some residents and delayed reporting of repair needs.
Deficiencies (1)
Failure to maintain two resident rooms (203 and 207) in a sanitary manner, including stained walls, ceilings, floors, and privacy curtains, presence of debris and insects, and loose bathroom tiles.
Report Facts
Residents Affected: 2
Timeframe: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Housekeeping Aide | Observed cleaning rooms in Hall 200 and interviewed regarding stains and cleaning issues. |
| Housekeeping Manager | Interviewed about cleaning observations and housekeeping procedures. | |
| Director of Maintenance | Interviewed regarding awareness of stains and repair procedures. | |
| Nursing Home Administrator | Interviewed regarding cleaning practices, resident compliance, and facility condition. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure appropriate placement was arranged prior to discharge for one resident (#5) and failure to administer medications as ordered for one resident (#3).
Complaint Details
The complaint investigation focused on Resident #5's discharge process, which was facility-initiated due to behavioral issues and inability to meet needs, but was not handled according to policy, including lack of proper notices and failure to offer a private room. For Resident #3, the complaint involved missed medication administrations without proper documentation or explanation.
Findings
The facility failed to ensure appropriate discharge planning and placement for Resident #5, resulting in a facility-initiated discharge that was not conducted per policy. Additionally, the facility failed to administer medications as ordered for Resident #3, missing doses without documented reasons.
Deficiencies (2)
Failed to ensure appropriate placement was arranged prior to discharge for Resident #5, including inadequate discharge planning and failure to follow facility policy for discharge.
Failed to administer medications as ordered for Resident #3, missing doses of Levothyroxine Sodium and Enoxaparin Sodium without documented reasons.
Report Facts
Missed medication administrations: 1
Missed medication administrations: 1
30-day discharge notice: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Interviewed regarding Resident #5's behavior and discharge. |
| Staff B | Certified Nursing Assistant | Interviewed regarding Resident #5's behavior and discharge. |
| Staff C | Certified Nursing Assistant | Interviewed regarding Resident #5's behavior and discharge. |
| Staff D | Certified Nursing Assistant | Interviewed regarding Resident #5's behavior and discharge. |
| Social Services Director | Social Services Director (SSD) | Interviewed about Resident #5's discharge planning and process. |
| Assistant Social Services Director | Assistant Social Services Director (ASSD) | Interviewed about Resident #5's discharge and roommate issues. |
| Regional Director of Clinical Services | Regional Director of Clinical Services (RDCS) | Interviewed regarding Resident #5's discharge and Resident #3's medication administration. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding discharge planning and incident involving Resident #5. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration policies and missed doses for Resident #3. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 11, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to assist dependent residents with activities of daily living, failure to provide timely pain management, and failure to maintain a functioning Quality Assurance Committee.
Complaint Details
The complaint investigation found substantiated issues including failure to provide scheduled showers and transfer assistance to residents #1, #6, and #7; failure to administer pain medication timely to resident #3; and failure to implement an effective Quality Assurance Committee as required.
Findings
The facility failed to provide scheduled showers and transfer assistance to dependent residents, delayed administration of physician-ordered pain medication for one resident for over nineteen hours, and did not have a fully functioning Quality Assurance Committee to monitor and correct quality deficiencies.
Deficiencies (3)
Failure to assist dependent residents with scheduled showers and transfer assistance.
Failure to provide timely pain management; resident did not receive physician-ordered pain medication for over nineteen hours.
Failure to maintain a functioning Quality Assurance Committee to review quality deficiencies and develop corrective plans.
Report Facts
Scheduled showers missed: 6
Pain medication delay (hours): 19
BIMS score: 15
BIMS score: 4
Tylenol dosage: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Occupational Therapist (OTR) | Involved in attempts to assist Resident #7 with transfer. |
| Staff D | Certified Nursing Assistant (CNA) | Assigned CNA to Resident #7, involved in transfer and snack provision. |
| Nursing Home Administrator | Unaware of missed showers and delayed pain medication. | |
| Regional Clinical Director | Confirmed delayed pain medication and initiated education. | |
| Orthopedic Consultant | Provided clinical context on Resident #3's condition and pain. | |
| Medical Director | Unaware of pain medication delay, emphasized need for nurse education. | |
| Staff E | Licensed Practical Nurse (LPN) | Reported on Resident #6's pain and medication administration. |
| Interim Director of Nursing | Discussed pain management and audit focus related to Resident #6. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jun 23, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, care, medication administration, food service, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, lack of physician orders for DNR status for some residents, inadequate incontinence care for one resident, medication administration errors related to insulin pen use, failure to follow planned menus and provide palatable, appropriately tempered food, failure to accommodate resident food preferences, improper food storage and unclean food service equipment, and inadequate infection control practices related to glucometer cleaning and hand hygiene.
Deficiencies (9)
Failed to treat residents with respect and dignity during meal service, resulting in disorganized meal delivery and lack of assistance for residents needing help.
Failed to ensure physician orders for Do Not Resuscitate (DNR) status were present and reflected in the electronic medical record for two residents.
Failed to provide necessary incontinence care to maintain personal hygiene for one resident.
Failed to ensure no significant medication errors related to insulin pen administration; specifically, insulin pens were not primed before use.
Failed to follow planned menus and provide meals as scheduled, including serving substituted or unplanned foods without proper documentation.
Failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for multiple residents.
Failed to ensure residents received food that accommodated allergies, intolerances, and preferences, including inability to request alternate meal choices.
Failed to ensure proper food storage and maintenance of clean preparation and serving equipment, including storing TCS foods beyond recommended time and unclean steam table and cutting boards.
Failed to follow infection control practices related to hand hygiene and cleaning/disinfection of glucometer used for blood glucose monitoring.
Report Facts
Incontinent episodes: 3.7
Temperature: 168
Temperature: 210
Temperature: 187
Temperature: 180
Temperature: 161
Temperature: 42
Temperature: 41
Temperature: 52
Temperature: 50
Temperature: 84
Temperature: 112
Temperature: 80
Temperature: 82
Temperature: 95
Temperature: 50
Temperature: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication administration error related to insulin pen use |
| Staff C | Licensed Practical Nurse (LPN) | Named in infection control deficiency related to glucometer cleaning and hand hygiene |
| Director of Food and Nutrition Services | Interviewed about meal service issues, menu substitutions, food quality, and cleaning concerns | |
| Director of Nursing (DON) | Interviewed about DNR orders, incontinence care, and medication administration | |
| Social Services Director (SSD) | Interviewed about audits related to code status | |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed about DNR documentation and insulin pen priming |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed about code status documentation |
| Staff Development Coordinator (SDC)/ Registered Nurse (RN) | Interviewed about insulin pen education and posters | |
| Infection Control Officer (IFC) | Interviewed about infection control practices related to glucometer use |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 26, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, psychotropic medication use, medication storage, and antibiotic stewardship at Bayshore Pointe Nursing and Rehab Center.
Findings
The facility was found deficient in multiple areas including failure to ensure accurate advance directive documentation, incomplete care plan implementation for wander/elopement alarms, failure to notify physicians of elevated glucose levels, delayed medication administration, incomplete psychotropic medication monitoring and consents, presence of expired medications, and inadequate antibiotic stewardship.
Deficiencies (7)
Failed to ensure physician order and accurate documentation of Do Not Resuscitate (DNR) status and care plan for advance directives for one resident.
Failed to implement care plan related to wander/elopement alarm and document checks of alarm functioning and placement for one resident.
Failed to notify physician of elevated glucose levels as ordered for one resident.
Failed to provide ordered medications in a timely manner to one resident due to delayed pharmacy delivery and prescription issues.
Failed to ensure consistent behavioral monitoring for psychotropic medications, obtain complete consents, and perform blood glucose monitoring for residents receiving insulin.
Failed to remove expired medications from medication cart and medication storage room.
Failed to implement antibiotic stewardship program ensuring appropriate antibiotic use and timely completion of urine analysis before antibiotic initiation.
Report Facts
Residents sampled: 32
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Expired medication found: 1
Expired medication found: 2
Expired medication found: 1
Missed behavioral monitoring shifts: 14
Missed behavioral monitoring shifts: 16
Missed psychoactive medication monitoring shifts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse (LPN) | Named in findings related to DNR status confusion and wander/elopement alarm documentation |
| Regional Clinical Director/ Interim Director of Nursing (DON) | Director of Nursing | Interviewed regarding DNR status, wander alarm orders, medication administration, psychotropic medication monitoring, and expired medication removal |
| Staff I | Licensed Practical Nurse (LPN) | Interviewed regarding medication delays for Resident #240 |
| Staff J | Registered Nurse (RN) | Interviewed regarding medication delays and antibiotic stewardship |
| Staff C | Licensed Practical Nurse (LPN) | Observed with expired medications on medication cart and storage room |
| Staff A | Registered Nurse (RN), Unit Manager | Interviewed regarding medication cart checks for expired drugs |
| Consultant Pharmacist | Interviewed regarding medication ordering, storage, and expired medication checks | |
| Infection Preventionist (IP) | Interviewed regarding antibiotic stewardship and lab work for Resident #244 |
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