Piper Shores

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping services necessary to maintain the building in a sanitary and comfortable environment on 2 of 2 wings (Prout's Neck and [NAME] Beach) for 3 of 3 days of survey.

Inspectors wroteBased on observations, record reviews, interviews and the facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 2 residents reviewed for respiratory care (Resident # 12 and #10). Findings 1. On 12/8/25 at 10:17 a.m., observation of Resident #12 receiving oxygen via a nasal cannula with the tubing labeled with a date of 11/28. At this time, Resident #12 stated he/she has oxygen on at all times. The electric wheelchair in his/her room had a travel oxygen pack with an unlabeled nasal cannula tubing wrapped up and hanging off the wheelchair handle. Next to the bedroom door was an oxygen cylinder stored in a caddy with an unlabeled nasal cannula wrapped up and stored hanging off the caddy handle. [...]

Inspectors wroteBased on observation, interview, record review and facility policy, the facility failed to ensure products in the walk-in refrigerator and freezer were labeled and/or dated and failed to remove expired foods available for use for 2 of 2 kitchen tours. (12/8/25 and 12/9/25) In addition, the facility failed to ensure the dish machine was maintaining proper temperature ranges for proper washing/rinsing/sanitizing.

Inspectors wroteBased on observation and interview, the facility failed to adequately date and properly dispose of open medications according to manufacturer specifications for 1 of 1 medication rooms observed. On 12/9/25 at 10:06 a.m. during an observation of the medication room with Registered Nurse (RN) #1, a surveyor observed an opened 30 milliliter, multi-dose, bottle of Lorazepam Intensol Oral Concentrate 2 milligram per milliliter with no open date, and with manufacturer recommendations to discard open bottle after 90 days. The RN then placed the bottle back into the refrigerator for use. On 12/9/25 at 11:35 a.m. during an interview, RN #1 stated they had pulled the undated medication from the refrigerator and then presented the controlled substance log to the surveyor that stated the bottle was opened on 8/6/25. On 12/9/25 at 11:37 a.m.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident record was complete and accurately reflected Certified Nursing Assistant (CNA) provided care for 1 of 1 resident reviewed. (Resident #11) Review of CNA Activities of Daily Living (ADL) documentation for Resident #11 for the months of November and December 2025 revealed missing documentation for scheduled daily activities including toileting, transfers and locomotion. Missing documentation was identified on 16 out of 30 days in November and 4 out of 9 days in December 2025. The CNA's task list indicated these cares were required daily; however, documentation was not completed consistently in the resident records. On 12/15/25 at 10:34 a.m. the above finding was discussed with the Director of Nursing

Inspectors wroteBased on interviews, record reviews and facility policy, the facility failed to ensure all facility staff maintain training in cardiopulmonary resuscitation (CPR) for Healthcare Providers.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that expired over the counter medications were removed from the supply that were available for use in 1 of 1 medication storage room and failed to ensure the medication room refrigerator was maintained at an acceptable temperature range for 15 of 39 days. In addition, the facility failed to ensure medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 3 survey days.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which included appeal rights and liability of payment, were provided at least 2 days prior to the resident's last covered day, for 2 of 3 residents whose Medicare Part A services were discontinued, and remained in the facility (#13, #21).

Inspectors wroteBased on observation and interview the facility failed to provide maintenance services necessary to maintain a sanitary and comfortable interior on 2 of 2 units observed (Prouts Neck Walkway and [NAME] Beach Walkway).

Inspectors wroteBased on observation, interview, and record review, the facility failed to be free of medication error rate of 5% or more. There was a total of 2 medication errors out of 29 opportunities. The medication error rate was 6.9%.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner relating to the ceiling air intakes vents and the over-the-stove exhaust hood in the main kitchen on the third floor.

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education record review, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training and the mandatory yearly training for dementia care 2 of 5 randomly selected CNAs employed greater than 1 year (CNA #3 and CNA #4).

Inspectors wroteBased on record review and interview, the facility failed to transmit a quarterly Minimum Data Set (MDS) electronically to the State MDS database within 14 days of completion date for 1 of 2 system selected residents reviewed for Resident Assessment (Resident #31).

Inspectors wroteBased on record review and interview, the facility failed to ensure its water management program was implemented and effective to prevent the growth of Legionella or other waterborne pathogens. This has the potential to affect all residents. Additionally, the facility failed to ensure proper hand hygiene post perineal care for 1 of 1 resident observed during care. (# 17).

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident's dignity by requiring a resident wear a clothing protector after stating that she/he does not want to wear one on 1 of 4 observations in the dining room. (#19).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 40 sampled residents observed for 1 of 3 days of survey (Resident #22).

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that a residents careplan was implemented, for 1 of 1 sampled resident reviewed for suicidal ideation ( #39). Findings; On 7/11/2023 a surveyor reviewed resident #39's care plan and noted: Category: 9 Behavior Problem lists Do not leave a gait belt in [Resident #39s] room. On 7/11/2023 at 12:17 pm a surveyor observed CNA#3 exit Resident #39s private bathroom with a gait belt. On 7/11/2023 at 12:40 pm a surveyor interviewed CNA#3 who confirmed that the gait belt was retrieved from resident's bathroom. CNA #3 confirmed that the gait belt is normally found in resident's room and they were unaware of the care plan stating gait belt was not be left in the room. On 7/11/2023 at 12:46 pm a surveyor interviewed CNA#1 and CNA#4 together and both confirmed the gait belt was normally stored in resident's room. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to follow up on a pharmacist recommendation timely, and failed to keep all copies of Medication Regimen Reviews (MRR) in the resident's permanent health record for 1 of 5 residents reviewed for medications (Resident #24).

Inspectors wroteBased on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which included appeal rights and liability of payment, were provided at least 2 days prior to the resident's last covered day, for 3 of 3 residents whose Medicare Part A services were discontinued, and remained in the facility (#39, #201, #202).

Inspectors wroteBased on interview and record review, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights and the name and address of the Office of the State Long-Term Care Ombudsman, to residents or their representative for 1 of 1 sampled residents transferred/discharged by the facility to an acute care hospital (Resident #11).

Inspectors wroteBased on record review and interviews, the facility failed to issue a bed hold notice for a facility initiated transfer/discharge to a resident, or his/her legal representative, for 1 of 1 sampled residents transferred to an acute care facility (#11).