Shoreline Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities for 3 of 4 residents (Residents 8, 55 & 71), reviewed for activities. This failure placed the residents at risk for dissatisfaction with their activity choices, poor psychosocial well-being, and boredom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food stored were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen refrigerator (Kitchen Walk-in refrigerator) and 1 of 8 staff (Staff T), reviewed for food services. The failure to discard food items and perform hand hygiene when assisting residents with their meals, 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 observation, interview, and record review, the facility failed to ensure the water management program included an Infection Preventionist and an appropriate agency to report an outbreak. Additionally, the facility failed to follow infection control practices for disinfection of shared medical equipment and/or hand hygiene by 2 of 8 staff (Staff I and Staff S) and ensure hand hygiene products and supplies were readily available and accessible for 1 of 1 medication room (Second Floor Medication Room), 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 environment were maintained for 2 of 2 rooms (Rooms 218 & 223), reviewed for environment. The failure to ensure resident rooms were maintained in good repair placed the residents at risk for less than homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments were completed accurately for 1 of 13 residents (Resident 6), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessment was marked on the MDS regarding weights 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 Preadmission Screen and Resident Review (PASRR or PASARR) Level II (refers to the evaluation process conducted after a Level I screening indicates a possible serious mental illness or intellectual disability to ensure that individuals receive appropriate care and support based on their specific needs and conditions) was obtained for 1 of 7 residents (Resident 6), reviewed for PASRR coordination. This failure placed the resident at risk of not receiving the necessary behavioral health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review (PASRR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 7 residents (Resident 4), reviewed for PASRR screening. This failure placed the resident at risk of not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised based on the resident's assessment for 1 of 13 residents (Resident 43), reviewed for care planning. This failure placed the resident at risk for unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician order was in place for continuous positive airway pressure (CPAP- a device used to treat sleep apnea [a condition where breathing repeatedly stops and starts during sleep]) settings and develop/implement care plan for CPAP for 1 of 1 (Resident 30), reviewed for respiratory care. This failure placed the resident at risk for respiratory related complications, respiratory infection, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled drugs were accurately accounted for 1 of 2 medication carts (East 2 Medication Cart), reviewed for controlled drugs management. This failure 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 ensure a physician's order was followed when administering medication for 1 of 5 residents (Resident 6), reviewed for unnecessary medications. This failure placed the resident at risk for side effects related to the medications, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was stored in accordance with professional standards and manufacturer specifications for 1 of 2 medication carts (East 2 Medication Cart), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to consistently maintain an established Antibiotic (medication to treat infection) Stewardship Program to promote the appropriate use of antibiotics for 2 of 6 residents (Residents 63 & 95) and failed to ensure standardized tools and criteria were utilized for Antibiotic Stewardship Program (such as Loeb Minimum Criteria [minimum set of signs symptoms used to determine whether to treat an infection with antibiotic]). These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and an increased risk for multi-drug-resistant organisms (microscopic organisms that are resistant to many antibiotics).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 1 of 1 dining room (Second floor Dining Room), reviewed for dining services. This failure placed the residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately store drugs and/or biologicals (diverse group of medicines made from natural sources) and medical supplies for 2 of 2 medication rooms (West 1 Medication Storage Room & Second Floor Medication Storage Room) and 1 of 3 medication carts (East 1 Medication Cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications/medical supplies.

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 1 of 1 dry storage room and 2 of 2 floors (First Floor & Second Floor), reviewed for food services. The failure to label food items and cover food items during meal tray delivery 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 observation, interview, and record review, the facility failed to ensure Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 35), reviewed for infection control. In addition, the facility failed to appropriately use Personal Protective Equipment (PPE -use of gown and gloves) and perform hand hygiene in the laundry room for 1 of 1 staff (Staff X), reviewed for infection control. These failures placed the residents, staff, and visitors at an increased risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered to 1 of 3 residents (Resident 65), reviewed for hospitalization. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 20 residents (Resident 20), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding preferences to guide the development of a comprehensive activity care plan placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement activity care plan for 1 of 20 residents (Resident 20), reviewed for care planning. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise comprehensive care plans for 3 of 20 residents (Residents 17, 20 & 6), reviewed for care plan revision. The failure to revise care plans for medication administration and behaviors with oxygen use 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 follow a physician's order in accordance with professional standards for 2 of 13 residents (Residents 26 & 335), reviewed for medications. These failures placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an activity program met the need of 1of 1 resident (Resident 20), reviewed for activities. The failure to implement an individualized ongoing program to support the resident in their choice of activities based on the comprehensive assessment and care plan placed the resident at risk for unmet activity pursuit, social isolation, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement bowel management protocol in accordance with professional standards of practice for 1 of 1 resident (Resident 48), reviewed for quality of care. This failure placed the resident at risk for discomfort, bowel impaction, and related complication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 3 of 5 residents (Residents 6, 16 & 285), reviewed for respiratory care. The failure to follow physician orders for oxygen therapy, properly store nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) and oxygen equipment placed the residents at risk for respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were accurate for 1 of 3 residents (Resident 32), reviewed for resident medical records. This failure placed the resident at risk for unmet care needs and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure admission Minimum Data Set (MDS) assessments were completed within 14 days of admission for 5 of 25 residents (Residents 20, 48, 67, 637 & 77) reviewed for comprehensive assessments. This failure placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately posted and updated with the actual hours worked for each shift for 4 of 5 days reviewed for sufficient and competent staffing. In addition, the facility failed to post daily nurse staffing in one of two prominent locations (Second Floor). This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation and interview, the facility failed to discard food products on or before their use by date in 1 of 1 walk in freezer (main kitchen walk-in freezer) and 1 of 1 walk-in refrigerator (main kitchen walk-in refrigerator). This failure placed the residents at risk for developing foodborne 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 medical equipment used in 9 of 9 residents' room (Rooms 221, 223, 211, 218, 120,115, 121, 122 & 116) were sanitized/disinfected between resident use, and failed to ensure hand hygiene practices were followed for 1 of 1 resident (Resident 81), reviewed for wound care. In addition, the facility failed to ensure 2 of 4 soiled utility rooms (West 1 and East 2) had an accessible sink for staff to perform hand hygiene and accessible garbage bin to dispose soiled materials and failed to ensure clean linens/personal clothing were transported properly. These failures 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 an updated guardianship letter was readily available in medical records and accessible to staff for 1 of 2 residents (Resident 37), reviewed for Advanced Directives (a written instruction, such as a living will or durable power of attorney for health care). This failure placed the resident and/or their representative at risk of losing their right to have their preferences honored to receive care according to their choice.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative when there was a significant weight loss for 1 of 4 residents (Resident 55) reviewed for nutrition. The failure to notify the resident's representative regarding the resident's significant weight loss placed the resident at risk of not having the representative involved in health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely significant change in status Minimum Data Set (MDS) assessment for 2 of 2 residents (Residents 24 and 63) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days 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 3 of 21 Residents (Residents 7, 40 & 25) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding the use of antibiotic (medication used to treat infection) and Insulin (medication used to improve/control blood sugar level) 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 the date of completion of Minimum Data Set (MDS) assessment was accurate for 1 of 8 residents (Resident 637) reviewed for resident assessment. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 3 of 20 residents (Residents 76, 63 & 24) reviewed for comprehensive care plans. The failure to develop and implement care plans for antibiotic (medication used to treat infection) use, toileting and nail 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 care plan interventions were initiated and revised for 2 of 2 residents (Residents 22 & 30), reviewed for care planning. This failure placed the residents at risk for poor hygiene, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal hygiene was performed for 1 of 4 residents (Resident 30) reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and diminished quality of life.