Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to develop care plans for the use of bed rails for
3 of 3 residents reviewed for bed rails, Residents #27, 56 and 62.
The findings included:
The facility's policy 'Side rails/Bed Rails' effective date 04/01/23, documented:
General Information:
4. If therapist determined that one or two half rails enhance bed mobility and/or facilitate independent
transfers from bed. These rails will be care planned for resident use.
6. M.D. order will be obtained for all side rail use.
1). Resident #27 was admitted to the facility on [DATE]. According to the resident's most recent full
assessment, a Significant Change Minimum Data Set (MDS), Resident #27 had a Brief Interview for Mental
Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS documented that the resident
had no impairments to upper and lower extremities and was able to roll from left to right in the bed.
Resident #27's diagnoses at the time of the assessment included: Orthostatic Hypotension,
Non-Alzheimer's Dementia, Depression, Psychotic Disorder, Myasthenia Gravis, Insomnia.
On 01/22/24 at 1:28 PM, Resident #27 was observed in bed sleeping on her right side with bilateral bed
rails raised. It was noted that there was a gap between the raised bed rails and the mattress that was large
enough that this surveyor was able place an arm between the bed rail and mattress to the resident's left
side of bed.
On 01/23/24 at 10:02 AM, Resident #27 was observed in bed sleeping on her back.
A review of Resident #27's electronic health record, revealed that the resident did not have any orders or
care plans for side rails/bed rails.
2). Resident #56 was admitted to the facility on [DATE]. According to the resident's most recent complete
assessment, a quarterly MDS, dated [DATE], Resident #56 had a BIMS score of 15, indicating that the
resident was 'cognitively intact'. The assessment documented that Resident #56 had no impairments to
upper and lower extremity and independently rolls left and right from lying in bed (bed mobility). Resident
#56's diagnoses at the time of the MDS included Heart failure, Hypertension, Anxiety
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
105492
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
disorder, Depression, Abnormalities of gait and motility, Lack of coordination, Muscle weakness, Insomnia,
Hereditary and Idiopathic Neuropathy, GERD, and Dizziness.
On 01/22/24 at 1:39 PM Resident #56 was observed in bed with her daughter filing her nails, with the bed
rail to the resident's left side of bed in the raised position. The resident's daughter stated that the facility
installed the bed rail because the resident would slide from the bed. Resident #56's daughter further stated
that there had been no incident related to the use of bed rail.
On 01/23/24 at 9:54 AM Resident #56 was observed in bed lying on the left side with rails in the raised
position.
Review of Resident #56's electronic health record revealed that the resident did not have a care plan for the
use of side rails/bed rails.
3). Resident #62 was admitted to the facility on [DATE]. According to the resident's most recent complete
assessment, a Significant Change MDS, dated [DATE], Resident #62 had a BIMS score of 03, indicating
severe cognitive impairment. The assessment documented that the resident did not have any impairments
to upper and lower extremity. Resident #62's diagnoses at the time of the assessment included: Atrial
Fibrillation, Cerebrovascular Accident, Non-Alzheimer's Dementia, Hemiplegia, Seizure disorder,
Depression, Encephalopathy, Degenerative Disease of Nervous System.
Review of the resident's electronic health record revealed that the resident did not have a care plan for the
use of bed rails/side rails.
During an interview, on 01/24/24 at 11:49 AM, with the Director of Nursing (DON), the DON acknowledged
understanding of the concerns.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 2 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain a resident's highest practicable level
of mobility for 1 of 3 residents reviewed for activities of daily living (Resident #32).
Residents Affected - Few
The findings included:
A review of the facility's policy Nursing- Activities of Daily Living (ADLs), dated 04/01/2022, documented:
The purpose was to ensure all residents needs are met in a manner that promotes their quality of life and
preferences. The facility shall ensure a resident is given the appropriate treatment and services to maintain
or improve his or her ability to carry out the activities of daily living. The facility shall provide care and
services for the following activities of daily living as needed based on the individual care plan of each
resident:
a. Hygiene- bathing, dressing, grooming, and oral care,
b. Mobility- transfer and ambulation, including walking,
c. Toileting
d. Dining- eating including meals and snacks,
e. Communication including speech, language and other functional communication systems.
A resident who was unable to carry out activities of daily living shall receive the necessary services to
maintain good nutrition, grooming, and personal and oral hygiene.
Resident #32 was observed lying in bed throughout the day on 01/22/24 and 01/23/24. An interview was
conducted with Resident #32 on 01/24/24 at 10:30 AM. The resident stated I'm just wasting away lying
here. Resident #32 stated he was receiving physical therapy some time ago, but since then he had not
gotten out of bed. Observed next to the resident's bed was a personal seated walker. The resident stated
they did not want him to use the walker to go to the bathroom. The resident stated he does not get out of
bed anymore, and would like to be moved around. He stated it was really uncomfortable lying in bed all day
in same position. Further observation of the resident's room revealed no chair or wheelchair available for
the resident's use.
Record review revealed Resident #32 was admitted to the facility on [DATE], with multiple readmissions,
and diagnoses which included Lung Disease and Skin Cancer. A comprehensive assessment dated [DATE]
documented the resident was cognitively intact, used a wheel chair for mobility, and partial/moderate assist
with activities of daily living.
Resident #32 was care planned for activities of daily living (ADL) self care performance deficit related to
impaired mobility, COPD (lung disease), generalized weakness, impaired balance, aging process, poor
motivation, resistant to getting out of (OOB)/ambulating/therapy/treatment. He has had a decline in function
due to refusing to ambulate/get OOB, hospice/terminal condition with decline expected. Interventions
included: Provide encouragement to participate to the fullest extent possible with each interaction. Provide
up to extensive assist of 1 with transfers, and monitor/document/report
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 3 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0676
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, and
declines in function.
An interview was conducted with the director of rehab on 01/24/24 at 12:00 PM. The Director stated the last
time Resident #32 received rehabilitation services was from 09/05/23-11/03/23. The Director stated
Resident #32 tried to use his personal walker, but was not supposed to use it without assistance. The
walker was unsafe to use. The resident was discontinued from rehab services due to lack of participation,
and had reached maximum participation. The Director stated they would do an evaluation of Resident #32
to see if he qualifies for additional services.
An additional interview was conducted with the Director of Rehab on 01/24/24 at 3:30 PM. The Director
stated an evaluation was completed on Resident #32. There was a significant decrease in strength since
discharged from rehab services on 11/03/23. Resident #32 was picked back up for services for 30 days.
An interview was conducted with Staff Z, a Registered Nurse, on 01/25/24 at 11: 20 AM. Staff Z stated
Resident #32 did not get out of bed due to refusal.
An interview was conducted with Staff Y, a Certified Nursing Assistant, on 01/25/24 at 11:25 AM. Staff Y
stated Resident #32 did not get out of bed due to refusal.
Further review of Resident #32's chart did not reveal any documentation of the resident's refusal to get out
of bed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 4 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and interview, the facility failed to administer oxygen as ordered for 1 of 2 residents reviewed
for respiratory therapy (Resident #32).
Residents Affected - Few
The findings included:
A review of the facility's policy Nursing- Oxygen Administration, dated 04/01/22, documented the purpose of
this procedure is to provide guidelines for safe oxygen administration. The following equipment and supplies
will be necessary when performing this procedure:
1. portable oxygen cylinder
2. nasal cannula, nasal catheter, or mask as ordered
3. humidifier bottle.
Resident #32 was observed in bed on 01/24/24 at 11:30 AM. The resident stated he was receiving oxygen
through his nose, and his nose gets congested. The resident stated he complained about it and had
received some medication for it in the past. A review of the resident's oxygen revealed the resident was
receiving 3 liters/minute of oxygen via a nasal cannula. Further observation revealed there was no
humidifier bottle (which provides moisture) attached to the oxygen.
An interview was conducted with the Respiratory Therapist (RT) on 01/24/24 at 12:15 PM. The RT stated, if
a resident was complaining of nasal congestion/dryness, a humidifier should be added to the oxygen
administration. If a resident was receiving oxygen at 3-4 liters/minute, the best practice was to add a
humidifier. RT added a humidifier to Resident #32's oxygen.
Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included
Lung Disease. A comprehensive assessment dated [DATE] documented the resident was cognitively intact
and received oxygen therapy.
Resident #32 was care planned for altered respiratory status with interventions which included oxygen
therapy as ordered.
A review of Resident #32's orders revealed an order for Oxygen Inhalation 2 liters/minute dated 09/06/23.
An additional order for Saline Nasal Spray 1 spray in both nostrils two times a day for stuffy nose from
12/14/23 until 01/09/24.
An interview was conducted with Staff Z, a Registered Nurse, on 01/25/24 at 11:30 AM. Staff Z confirmed
Resident #32 was receiving 3 liters/minute of oxygen instead of the 2 liters/minute ordered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 5 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide trauma informed care in a manner to
eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed for behavior,
Resident #36.
Residents Affected - Few
The findings included:
Resident #36 was admitted to the facility on [DATE]. According to the resident's most recent complete
assessment, an Annual Minimum Data Set (MDS), dated [DATE], Resident #36 had a Brief Interview for
Mental Status score of 15, indicating that the resident was cognitively intact. Resident #36's diagnoses at
the time of the MDS included: Cerebral Palsy, Quadriplegia, Anxiety disorder, Schizophrenia,
Post-Traumatic Stress Disorder (PTSD), Spondylopathy of Lumbosacral Region, History of UTI,
Lymphocytopenia, Hereditary and Idiopathic Neuropathy.
A review of the resident's Electronic Health Record revealed that the resident did not have a care plan for
PTSD.
During an interview with Resident #36, on 01/23/24 at 9:00 AM, when asked about the diagnosis of PTSD,
Resident #36 replied, It stems from childhood abuse. When asked about triggers of PTSD, Resident #36
replied, the trigger is when you are institutionalized, and I feel stuck somedays and my brain goes to safety
mode right away. If I were to take a cold shower, that would trigger. When the water is cold, I don't like cold
water. They (referring to the facility nursing staff) should be aware of it. It is from physical and sexual abuse.
I am taking medication for it too.
During an interview, on 01/24/24 at 1:26 PM, with Staff A, CNA at the facility for 23 years, when asked of
her knowledge related to PTSD, Staff A was not able to demonstrate knowledge of PTSD and was not able
to demonstrate awareness of Resident #36's triggers and associated behaviors.
During an interview, on 01/24/24 at 1:40 PM, with Staff B, CNA at the facility since 2000, Staff B was not
able to demonstrate knowledge of PTSD and was not able to demonstrate awareness of Resident #36's
triggers and associated behaviors.
During an interview, on 01/24/24 at 1:51 PM, with Staff C, RN at the facility for 4-5 years, the RN was not
able to demonstrate awareness of Resident #36's triggers and associated behaviors. Staff C stated, I don't
see him on much medication for that, I was on vacation. He is always nice to us.
During an interview, on 01/24/24 at 2:58 PM, with the Regional MDS Coordinator, the MDS Coordinator
confirmed there was no care plan related to the Resident's PTSD.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 6 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure correct use of side rails, assess the
residents for risk of entrapment from side rails, failed to obtain informed consent prior to use of side rails
and failed to conduct regular maintenance checks on side rails for 3 of 3 residents reviewed for side rails,
Residents #27, 56 and 62.
The findings included:
The facility's policy, 'Siderails/Bedrails', effective date 04/01/23, documented:
8. All side rails in use whether or not they are restraints must be carefully assessed for risk of entrapment.
The maintenance department upon placement of the side rails wil complete a bed system audit to ensure
proper placement of side rails.
9. The maintenance department will also complete a bed system audit any time a side rail is added or
removed from a bed and whenever a mattress is changed or bolster/wedge is added or removed.
10. The maintenance department will also complete a bed system audit bi-annually of all beds in the facility
to ensure that no mattress, bolster/wedge, siderail, or enabler bar has gaps that are larger than
recommended.
11. All maintenance staff will be trained on how to properly measure the open spaces between the bed
system components and assess the seven potential zones for resident entrapment.
1). Resident #27 was admitted to the facility on [DATE]. According to the resident's most recent full
assessment, a Significant Change Minimum Data Set (MDS), Resident #27 had a Brief Interview for Mental
Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS documented that the resident
had no impairments to upper and lower extremities and was able to roll from left to right in the bed.
Resident #27's diagnoses at the time of the assessment included: Orthostatic Hypotension,
Non-Alzheimer's Dementia, Depression, Psychotic Disorder, Myasthenia Gravis, Insomnia.
A 'Bed Rail(s) Informed Consent for Use', dated 08/16/23 documented:
In the section of the consent form for 'Reason Bed Rail(s) is Being Considered':
What assessed medical needs for this resident would be addressed by the use of bed rail(s)? Staff D
answered Yes.
Alternatives attempted that failed to meet resident's needs: Staff D answered Resident needs for
positioning and mobility.
On 01/22/24 at 1:28 PM, Resident #27 was observed in bed sleeping on her right side with bilateral bed
rails raised. It was noted that there was a gap between the raised bed rails and the mattress that was large
enough that this surveyor was able to place an arm between the bed rail and mattress on the resident's left
side of bed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 7 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
2). Resident #56 was admitted to the facility on [DATE]. According to the resident's most recent complete
assessment, a quarterly MDS, dated [DATE], Resident #56 had a BIMS score of 15, indicating that the
resident was 'cognitively intact'. The assessment documented that Resident #56 had no impairments to
upper and lower extremity and independently rolls left and right from lying in bed (bed mobility). Resident
#56's diagnoses at the time of the MDS included Heart failure, Anxiety Disorder, Depression, Abnormalities
of Gait and Mobility, Lack of Coordination, Muscle Weakness, Insomnia, Hereditary and Idiopathic
Neuropathy, GERD, and Dizziness.
A 'Bed Rail(s) Informed Consent for Use', dated 08/16/23 documented:
In the section of the consent form for 'Reason Bed Rail(s) is Being Considered':
What assessed medical needs for this resident would be addressed by the use of bed rail(s)? Staff D
answered Yes.
Alternatives attempted that failed to meet resident's needs: Staff D answered Resident needs for
positioning and mobility.
On 01/22/24 at 1:39 PM Resident #56 was observed in bed with her daughter filing her nails, with the bed
rail to the resident's left side of bed in the raised position. The resident's daughter stated that the facility
installed the bed rail because the resident would slide from the bed. Resident #56's daughter further stated
that there had been no incident related to to the use of bed rail.
During the observation, it was noted that there was a gap between the raised bed rails and the mattress
that was large enough that this surveyor was able to place an arm between the bed rail and mattress on the
resident's left side of bed.
3). Resident #62 was admitted to the facility on [DATE]. According to the resident's most recent complete
assessment, a Significant Change MDS, dated [DATE], Resident #62 had a BIMS score of 03, indicating
severe cognitive impairment. The assessment documented that the resident did not have any impairments
to upper and lower extremity. Resident #62's diagnoses at the time of the assessment included: Atrial
Fibrillation, Cerebrovascular Accident, Non-Alzheimer's Dementia, Hemiplegia, Seizure Disorder,
Depression, Degenerative Disease of Nervous System.
Review of Resident #62's Electronic Health Record revealed that there was no informed consent for the use
of bed rails prior to survey.
On 01/24/24 at 9:44 AM, Resident #62 was observed in bed with side rails in the raised position. During the
observation, it was noted that there was a gap between the raised bed rails and the mattress that was large
enough that this surveyor was able to place an arm between the gap between bed rail and mattress on the
resident's left side of bed.
During a room by room observation, on 01/24/24 at 9:45 AM accompanied by the Regional Maintenance
Director, the spaces between the residents' mattresses were measured by the Regional Maintenance
Director using a tape measure and the following were revealed:
The space between the mattress and the side rail on Resident #27's right side of bed measured
approximately four and one half inches.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 8 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
The space between the mattress and the side rails on Resident #56's right side of bed measured
approximately five inches.
The space between the mattress and the side rail on Resident #62's right side of bed measured
approximately four inches.
Residents Affected - Few
The space between the mattress and the side rail on Resident #62's left side of bed measured
approximately four and one half inches.
During an interview, on 01/24/24 at 9:46 AM, with the Regional Maintenance Director and the Maintenance
Assistant, when asked about installing and auditing the bed rails, the Maintenance Assistant replied, as
soon as we get an order for therapy, we install them. They tell us if there is a problem with the bed. I check
by shaking and making sure it is not loose. Make sure that it is in the right position.
The Regional Maintenance Director stated, The nurses and the therapists do audits on the beds. They tell
us if there is a problem with the bed.
During an interview, on 01/24/24 at 10:16 AM with the Director of Rehabilitation, when asked about the
informed consents for the use of the bed rails and the residents being assessed for the use of bed rails,
including assessing for the potential of entrapment and the risks of entrapment, the Director of
Rehabilitation replied, we assess the patient to see if they are appropriate and if they require them, we let
the nurse (referring to Staff D, RN) know and we let Maintenance know and we fill out a form. I audit to see
if they need them. When asked about assessing residents for the use of side rails and the risks associated
with them, the Director of Rehabilitation stated, we assess the patient to see if they are appropriate and if
they require them, we let the nurse know and we let Maintenance know and we fill out a form. I audit to see
if they need them. It is Maintenance's job to check to see if they fit and are properly fitted, because they are
the ones that put them on and take them off.
During an interview, on 01/24/24 at 10:26 AM, the Maintenance Assistant stated that he does not conduct
audits of the bedrails.
During an interview, on 01/24/25 at 11:49 AM with the Director of Nursing (DON), when asked about
auditing the bed rails, the DON replied, Maintenance puts them in. After Maintenance puts them in, therapy
and nursing are responsible for auditing the side rails and if we think it is not necessary for them to have
side rails, we let therapy know. We check if the rails are tight and not loose, if they fit the bed.
The facility was not able to provide documentation of the residents being assessed for the potential of
entrapment and the risks associated with entrapment, up to including impairment and/or death.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 9 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An
observation of the facility's laundry room was conducted on 01/25/24 at 12:00 PM. The following concerns
were identified on the designated clean side:
Residents Affected - Few
a. Two commercial washers with dirt and debris on the outside.
b. Dirt/trash on the floor between and around the commercial washers.
c. Air vents with dirt/debris hanging.
d. Dust on top of commercial dryers.
e. Dust on windowsill/walls near dryers.
f. Dirty cupboard next to the folding table
g. Personal items in the folding area (employee jacket, phone charger, ect).
h. Dirty rolling chair with stains on the cushion.
i. Rust stained carts for clean clothing.
The above was discussed with the administrator on 01/25/24 at 1:00 PM.
Based on interview, observation, and record review, the facility failed to correctly verify the physician's order
related to contact isolation for 1 of 1 resident reviewed for transmission-based precautions, Resident #62;
and the facility failed to maintain the laundry room in a clean and sanitory manner.
The findings included:
1. The facility's policy titled, Isolation- initiating Transmission Based Precautions with an effective date of
4/01/22,has General guidelines relating to requirements for implementing and maintaining Transmission
Based precautions. Item 5, has the following statement: When Transmission- Base Precautions are
implemented, the Infection Preventionist (or designee) shall: . There is a list of requirements to be
implemented. This list includes the following:
a. Ensure that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained near the resident's room
so that everyone entering the room can access what they need.
b. Post appropriate notice on the room entrance door and on the front so that all personnel should be aware
that they must see a nurse to obtain additional information about the situation before entering the room.
On 1/22/24 at approximately 3:30 PM, while conducting record review, a determination was made that
Resident #62 had an order for Contact Isolation. This order was in place from 01/15/24. An immediate
observation of the room was made where it was determined that there was no sign posted regarding
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 10 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105492
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beach Breeze Rehab and Care Center
1626 Davis Rd
West Palm Beach, FL 33406
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the isolation nor was there required Personal Protection Equipment (PPE) associated with Transmission
Based Precautions (TBPs) as indicated in the facility's Infection Control protocols regarding TBPs.
Repeated observations of Resident #62's room and door were made as follows: on 01/23/24 at 09:10 AM,
on 01/23/24 at 3:40 PM and on 01/24/24 at 10:02 AM. There were no signs posted or PPE available for
those observations. On 01/24/24, at 10:27 AM, an observation was made of the room. At the time of the
observation the facility had placed a Contact Isolation sign on the door and a cart of PPE had been placed
to the left of the door as one would have entered the room.
Further review of resident records showed an entry into the nursing progress note dated 01/15/24 at 2:26
AM. The note indicates Resident #62 was admitted from the hospital with the diagnoses of Respiratory
Failure and MSRA. The MRSA was noted to be in the form of Bacteremia, which indicates it was a
bloodborne pathogen. Resident #62 was admitted with a Peripherally Inserted Central Catheter (PICC) and
had discharge orders for an Intravenous (IV) antibiotic to be administered once a day until 02/01/24. The
order for Contact Isolation was placed approximately the same time the progress note was documented.
On 01/24/24 at 10:30 AM, an interview was conducted with the Infection Preventionist (IP). The IP
explained Resident #62 arrived from the hospital, on 1/14/24 during the 11 PM- 7 AM shift, with the
Diagnosis of MRSA. The resident was ordered IV antibiotics to be administered once daily until 02/01/24.
The IP claimed the resident had the contact precautions sign and PPE initially upon admission. The IP
explained the Clinical Team, which usually consists of the DON, the ADON, the Infection Preventionist and
the Nurse Practitioner, discussed Resident #62's case on 01/15/24 regarding whether the contact isolation
should remain or could be removed based upon the time the resident had already been receiving treatment
for the MRSA. The Infection Preventionist was absent on that day. The Infection Preventionist stated that he
would not have removed the PPE and Isolation sign while the resident had an active infection without
discussing this with the doctor first.
On 01/24/24 at 11:30 AM, an interview was conducted with the Director of Nursing (DON) regarding the
contact isolation order related to the facility's Transmission Based Precautions protocol. The DON explained
that the admitting nurse put the resident on contact isolation because the resident had a MRSA diagnosis.
This follows protocols. The DON stated she discussed the need for isolation with the nurse practitioner on
Monday, 01/15/24. The DON stated that she and the nurse practitioner assessed the resident's wound, and
the nurse practitioner told the DON that because there was no drainage the staff only needed to use gloves
for the dressing change and a gown was not needed. The DON stated she could not recall if the nurse
practitioner told her she could remove the isolation. There was no documentation done at the time to
indicate if isolation was removed. The order for isolation had not been discontinued at the time of this
interview. The DON was asked if she was aware that the MRSA was identified as Bacteremia and not in the
wound, the DON stated she was aware.
On 01/25/24 at approximately 9:00 AM, an observation was made that the Transmission Based Precautions
sign and PPE had been removed from room [ROOM NUMBER]. A check of Resident #62s' orders revealed
the Contact Isolation order had been discontinued and the order was no longer found among the active
orders. The discontinuation date was 01/24/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105492
If continuation sheet
Page 11 of 11
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
FAQ · About this visit
Common questions about this visit
What happened during the January 25, 2024 survey of BEACH BREEZE REHAB AND CARE CENTER?
This was a inspection survey of BEACH BREEZE REHAB AND CARE CENTER on January 25, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BEACH BREEZE REHAB AND CARE CENTER on January 25, 2024?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.