Park Shore

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure handrail/support bars in resident bathrooms were maintained and were safe to use for 3 of 4 residents (Residents 23, 24 & 25) and failed to ensure plastic bags were not used as light switch pullcords for 2 of 4 residents (Residents 24 & 11), reviewed for environment. Additionally, the facility failed to ensure a homelike environment when medications were administered in the dining room for 1 of 11 residents (Resident 2), reviewed for medication administration. These failures placed the residents at risk for injury, a less than homelike environment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured for 2 of 2 medication carts (Medication Cart 1 and Medication Cart 2), reviewed for medication storage. This failure placed the residents at risk to have unintended access to medications and biologicals that should have been locked and/or compromised medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 5 of 5 refrigerators (PM [Evening] Production Floor Refrigerator, Walk-in Main 2 Refrigerator, Dairy Healthcare (HC)/Assisted Living (AL)] Dressing 3 Refrigerator, Second Floor Kitchen Refrigerator & Second Floor Resident Supplement Refrigerator), reviewed for food services. The failure to label and discard food items past the use by/best by date, placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precaution (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 2 of 9 residents (Residents 5 & 2), and failed to ensure Transmission Based Precautions (TBP- measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment [PPE-use of gown, gloves, mask and/or face shield] before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 1), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident dignity was maintained related to indwelling urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) use for 1 of 2 residents (Resident 8), reviewed for dignity. This failure placed the resident at risk for decreased self-worth and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice with the required information for 2 of 3 residents (Residents 5 & 3), reviewed for discharge process. This failure placed the residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 8 residents (Resident 10), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for 2 of 8 residents (Residents 5 & 16), reviewed for comprehensive care plans. The failure to develop a care plan for antibiotic (medication to treat infections) use and discharge plan placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor residents taking diuretic (used to treat fluid retention or swelling) medications and/or failed to notify the provider of weight loss/gain for 3 of 4 residents (Residents 4, 10 & 11), reviewed for weight monitoring. The failure to obtain/monitor weights and measure abdominal girth (measurement around the abdomen) placed the residents at risk for unrecognized weight loss/gain, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 1 of 2 residents (Resident 22), reviewed for respiratory care. The failure to properly store oxygen and nebulizer (medical device that turns liquid medication into a fine mist that can be inhaled through a mouthpiece or mask) equipment placed the resident at risk for respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 residents (Resident 4 & 16) were free from significant medication errors. The failure to document and/or provide medications placed the residents at risk for complications, decline in medical condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for 30 of 30 days (11/08/2025 to 12/08/2025), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine and as needed medications as prescribed by the physician to meet the needs of 3 of 3 residents (Residents 1, 2 & 3), failed to ensure controlled drugs were accurately accounted for and timely discarded for 2 of 2 residents (Residents 1 and 4), reviewed for medication management and controlled drugs. In addition, the facility failed to document medication administration in accordance with professional standards for 1 of 1 resident (Resident 5), reviewed for medication administration. These failures placed residents at risk for uncontrolled pain, medication errors, negative outcomes, and placed the facility at risk for potential loss and/or drug diversion of the controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for 3 of 4 residents (Resident 1, 2 & 3), reviewed for incident investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse and/or neglect, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored were labeled/dated and discarded after the expiration date or use by date in accordance with professional standards for food safety for 2 of 2 refrigerators (Dairy Refrigerator and Main Walk-In Refrigerator) and 1 of 1 freezer (Walk-In Freezer), reviewed for food services. This failure placed the residents at risk for food borne illness [caused by the ingestion of contaminated food or beverages] and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of fruit flies (small insects that are attracted to ripe, rotting, or fermenting fruits and vegetables) in the kitchen area of the facility. This failure placed residents at risk for infection, maggot infestation (small, worm like bugs that hatch from fly eggs) and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure glucometers (portable device used to measure blood sugar) were disinfected properly for 2 of 2 residents (Residents 168 & 14), clean insulin [medication that works by lowering levels of sugar in the blood] pen rubber seal prior to attaching a needle for 2 of 2 residents (Residents 168 & 14), and ensure Enhanced Barrier Precautions (EBP- gown and glove use to protect residents from multidrug-resistant organism [germ that is resistant to medications that treat infections]) practices were followed for 2 of 5 residents (Residents 12 & 68), reviewed for infection control. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 10 residents (Resident 11), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding active diagnosis placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - a federally required screening of all individuals who has both an Intellectual Disability [ID] or Related Condition [RC] and a Serious Mental Illness [SMI] prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 3 of 5 residents (Residents 11, 14 & 68), reviewed for unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnosis or disability.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for 3 of 8 residents (Residents 14, 2 & 6), reviewed for comprehensive care plan. The failure to implement care plans for Activities of Daily Living (ADL), use of medication to reduce swelling, and use of psychoactive [mind-altering] medication to include target behaviors and non-pharmacological interventions placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive care plan for 1 of 10 residents (Resident 11), reviewed for care plan revision. The failure to revise the care plan for use of a diuretic (reduce swelling/fluid buildup in the body) and psychoactive [mind-altering] medications placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary assistance with showering/bathing for 1 of 2 residents (Resident 2), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 1 resident (Resident 2), reviewed for hospice services. In addition, the facility failed to ensure adverse side effects for diuretic medication (that helps with edema [swelling] to reduce fluid buildup in the body) use and monitoring of edema were conducted for 1 of 1 resident (Resident 11), reviewed for unnecessary medications. These failures placed the residents at risk for not receiving necessary comfort care services, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure target behaviors and non-pharmacological interventions were identified and monitored for residents receiving psychotropic medications (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) for 2 of 5 residents (Residents 6 & 11), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals for 1 of 1 medication refrigerator, reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure used N95 respirator/mask were discarded, disinfection of face shields were conducted, and use of proper N95 were followed when caring for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) positive residents in 4 of 4 rooms (Rooms 202, 204, 206 & 208) to non-COVID positive resident in 1 of 1 room (room [ROOM NUMBER]), reviewed for infection control. This failure placed the residents at risk for facility acquired or healthcare-associated infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure fall interventions were updated, to ensure care was provided to residents at the care level they were assessed to required, and that care staff had access to fall prevention interventions for 1 of 2 resident (Resident 8) reviewed for falls. This failure caused harm to Resident 8 who fell while ambulating and experienced a fractured left humerus (long bone in the arm that runs from the shoulder to the elbow). In addition, the facility failed to ensure 1 of 1 housekeeping storage rooms, reviewed for accident hazards, was locked. These failures placed all residents at potential risk for avoidable falls, injury, unsafe exposure to potentially hazardous cleaning chemicals, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that unless the facility employed a full time Registered Dietitian, the director of food and nutrition services had completed an academic program in nutrition or dietetics (the application of the science of nutrition to the human being in health and disease) accredited (officially recognized or authorized) by an appropriate national accreditation organization. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the foods stored in the kitchen were labeled/dated when first opened and ensure thermometers were properly sanitized between use for 2 of 2 kitchen (Main Kitchen and Second Floor Kitchen). In addition, the kitchen staff failed to put on hair restraints while preparing/cooking foods in the Main Kitchen. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment was updated to accurately determine and identify the resources needed for the facility's resident care needs. This failure had the potential to affect the provision of care and services for the residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan (CP) for 6 of 8 residents (Residents 7, 8, 6, 4, 9 & 13) reviewed for comprehensive person-centered care plan. The failure to develop CPs for residents' skin condition, edema (swelling), pain, self-administration of medications, walker, behavior, and respiratory care placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clean linens were covered while transported to the second floor for 3 out of 3 linen closets (linen rooms 1, 2 and 3). In addition, the facility failed to consistently ensure policies and procedures (P/Ps) related to infection prevention and control were reviewed annually as required and the facility failed to perform hand hygiene during wound care. These failures placed the residents at risk for facility acquired or healthcare associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a self-medication administration assessment for 1 of 1 resident (Resident 6) reviewed for medication at bedside. The failure to complete a self-administration medication assessment placed the resident at risk for medication errors and adverse medication interactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directives was obtained from the residents/representatives who have an Advanced Directives in place and ensure a copy was readily available in the medical records for 2 of 4 residents (Residents 10 and 9) reviewed for Advance Directives. This failure placed the residents at risk of losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations.

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility - Advance Beneficiary Notices (SNF- ABN) to 2 of 3 residents (Residents 10 & 168) reviewed for beneficiary notifications. The failure to provide residents the information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program.

Inspectors wroteBased on interview and record review, the facility failed to report a fall with substantial injury to the State agency within 24 hours for 1 of 1 (Resident 8) reviewed for reporting. This failure placed the residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation for a fall with substantial injury for 1 of 1 (Resident 8) reviewed for falls. This failure placed the residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) assessment for 1 of 2 residents (Resident 5) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to complete and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 2 of 11 residents (Residents 2 & 5) whose Minimum Data Set (MDS - an assessment tool) were reviewed for timeliness in completion and transmission/submission. The failure to ensure timely completion and transmission of MDS assessments and tracking records placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 2 of 11 residents (Residents 5 and 13) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding prognosis of life expectancy of less than 6 months, pressure ulcer/injury (to skin and underlying tissue resulting from prolonged pressure on the skin), and Preadmission Screening and Resident Review (PASRR) placed the residents at risk for unidentified or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for 1 of 5 residents (Resident 13) reviewed for PASRR. This failure placed the resident at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission to ensure continuity of care and/or to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 2 of 3 residents (Residents 166 & 116) reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to review and revise Care Plans (CPs) for 1 of 8 residents (Residents 8) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for unidentified/unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to do skin evaluations, implement monitoring and interventions for skin care for 2 of 3 residents (Residents 7 & 166) reviewed for skin conditions. Additionally, the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 2 residents (Resident 5) reviewed for hospice services. These failures placed the residents at risk for wound infection, not receiving the necessary wound/skin treatments, not receiving necessary comfort care services, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident receive necessary treatment, consistent with professional standards of practice to an existing pressure ulcer ( also known as pressure sores, are localized damage to the skin and/or underlying tissue that usually occur over bony parts of the body) for 1 of 1 resident (Resident 13) reviewed for pressure ulcer. This failure placed the resident at risk of worsening pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary foot care in accordance with professional standards for 1 of 1 resident (Resident 7) reviewed for ADLs (ADLs-Activities of Daily Livings) and foot care. This failure placed the resident at risk for pain/discomfort and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care of a suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) including the suction tubing and suction canister for 1 of 2 crash cart (a medical device containing necessary equipment and supplies for use during emergencies) (Suction Machine in Second Floor Dining Room/Solarium). Additionally, the facility failed to ensure oxygen (O2) therapy was given according to standards of practice for 1 of 1 resident (Resident 13) reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on for 1 of 5 residents (Resident 6) reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications, medication-related adverse consequences, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and store medications (no open date or not dating medications after opening it) and failed to ensure expired medications were disposed of timely in accordance with current accepted professional standards for 1 of 1 medication storage room and 1 of 2 medication carts (Cart 2) reviewed for medication storage. Additionally, the facility failed to maintain proper temperature for 1 of 2 refrigerators in the medication storage room (Refrigerator 1 for medication). This failure placed the residents at potential risk to receive expired medications and to receive compromised or ineffective medications with unknown potency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pre-planned menu posted in the dining room was accurately posted and updated with the current menu for 1 of 1 dining room (Second Floor Dining Room). This failure placed the residents, their representatives, and visitors at risk of not being fully informed of the current pre-planned menu.