Shoreline Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for two of five sampled residents (Resident 82 and Resident 46) as evidenced by:A. Failing to ensure Resident 82 was dressed in the resident's own clothing appropriate to the time of day and consistent with the resident's preferences instead of hospital gowns. B. Failing to ensure staff spoke to Resident 46 in a respectful manner. These failures had the potential to negatively affect Resident 82 and 46's sense of dignity, autonomy (the ability to make your own choices and control your own actions), and psychosocial well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for two of four sampled residents (Resident 2 and 5) with limited ROM and mobility (ability to move) concerns. a. For Resident 5, the facility failed to:1. Objectively measure Resident 5's ROM in both arms during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluations, dated 5/6/2025 and 11/11/2025.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Administer polyethylene glycol (laxative to relieve constipation) correctly to one of four sampled residents (Resident 30).2. Administer pregabalin (medication used to treat nerve pain) to one of one sampled residents (Resident 6) and did not notify the physician or clarify administration on 5/20/2026, 5/31/2026, 6/4/2026, and 6/20/2026. This deficient practice had the potential to result in increased risk of constipation for Resident 30 and unrelieved pain for Resident 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 6/22/2026 by failing to:1. Ensure nine residents on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received corn texture in form that meet their needs and in accordance with international Dysphagia Diet Initiative (IDDSI-a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed corn was dry, lumpy, not smooth and had pieces of corn present requiring chewing before swallowing.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was prepared by methods that conserved flavor and served at appetizing temperatures for 64 out of 67 residents who received food from kitchen and for Resident 4 who complained that food was cold and Resident 6 who complained food texture was chewy not palatable. This deficient practice had the potential to result in meal dissatisfaction, decreased food intake and placed residents at risk for unplanned weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 24 sampled residents were served the food preference listed on the lunch tray cards (a printed sheet that includes resident diet order, preferences and dislikes) when:1. Resident 43 food preferences were not honored when corn was served during lunch, despite corn being listed as a dislike on resident's lunch tray card.2. Resident 8 whose diet order indicated vegan (a person whose diet does not include animal products) received whole milk and dairy ice cream for lunch on 6/22/2026)These deficient practices had the potential to result in decreased meal satisfaction, decreased caloric intake, and negatively affect nutritional status of residents whose food preferences were not honored for lunch.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. One juice machine dispenser nozzle was dirty with dried red color residue.2. One reach in freezer (a commercial upright standing refrigeration unit with standard front door allows staff to quickly grab, store or organize items on shelving.) bottom shelf was dirty with food debris.3. The (Robot Coupe) Food processor bowl was wet, not air dried and not clean after they were washed, there was water inside the bowl and food stains stuck on the lid. One blender jar was not maintained clean. The base of the blender jar was covered with a gel seal. The seal was torn and not smooth to clean and sanitize. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for two of four sampled residents (Resident 3 and 5) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) concerns and failed to develop and implement a policy and procedure for medical record accuracy. a. For Resident 3, the facility failed to:1. Accurately document Resident 3's inability to perform sit-to-stand transfers and ambulation for 10 feet (unit of measure) during multiple dates from 4/2026 to 6/2026.2. Document Resident 3's sitting tolerance in the wheelchair during Physical Therapy ([PT] profession aimed in restoration, maintenance, and promotion of optimal physical function) Treatment sessions prior to discharge from PT services on 6/25/2026. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold notice upon transfer for one of one sampled residents (Resident 68). This deficient practice had the potential to result in the resident or responsible party not knowing their rights and not being able to return to the facility.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to meet professional standards and clarify the doctor's orders and plan of care for one of five sample residents (Resident 30). This deficient practice placed Resident 30 at risk for experiencing unmanaged pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to address the following for one of five sampled residents (Resident 3): 1. Failed to ensure Resident 3's foley catheter (f/c: a hollow tube inserted into the bladder to drain or collect urine) urine output was monitored and documented.2. Failed to implement Resident 3's care plan for monitoring R for edema (swelling caused by excess fluid trapped in the body's tissues) and urine output. These deficient practices placed Resident 3 at risk for complications related to unmanaged fluid balance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 61) was positioned above 30 degrees while enteral feeding (G-tube - the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) was being delivered. This failure had the potential to place the resident at risk for aspiration (accidental breathing of food, liquid, or stomach contents to the airway and lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement non-pharmacological interventions for one of one sampled resident (Resident) 26 prior to administering pain medication. This failure had the potential to place the resident at risk for the increased use of unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of 24 sampled residents (Resident 9) dialysis subclavical (anatomical structure situated directly beneath the clavicle (collarbone) port was covered. This deficient practice had the potential to delay or lack of identifying complications (such as pain, infection, accidental trauma, and dislodgement) of the dialysis access site and could lead to a delay provision of dialysis treatment. Findings During an observation on 6/23/2026 at 8:34 a.m., Resident 9's right dialysis port, located beneath the collarbone, was noted to be exposed with tape residue present. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to implement its policy and procedure (P&P) titled, Infection Prevention and Control Program: Infection Prevention-Foley Catheter and Central Lines revised 12/2024, for one out of 24 sampled residents (Resident 9) by failing to ensure staff took off the non-sterile gloves (everyday disposable gloves that are clean and safe for general use, but have not undergone special treatments to kill all microorganisms) prior to putting on sterile gloves to apply a clean dressing on Resident 9's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) subclavical part of the body situated directly beneath the collarbone) port (surgically created site that allows blood to safely flow through a dialysis machine for filtering) This deficient practice had the [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was admitted back to the facility after Resident 5 was evaluated and cleared by the General Acute Care hospital (GACH) to return to the facility on 6/5/2026. These deficient practices resulted in a delayed admission from the GACH back to the facility from 6/5/2026 to 6/12/2026 and had the potential to cause psychosocial harm top Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) documented Resident 1's refusal to allow belongings to be inventoried for one of three sampled residents (Resident 1). This failure resulted in the facility being unable to determine the contents of Resident 1's backpack, including the amount of cash Resident 1 later reported missing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and unobstructed egress and flooding of water from under the exit door for four of four sampled residents (Resident's 1, 3, 6 and 7) when staff positioned Resident 1's bed partially blocking the exit door and when heavy rain allowed water to enter through the exit door, creating an unsafe exit route. This deficient practice had the potential to impede the safe evacuation for Residents 1, 3, 6, and 7 during an emergency and placed residents, staff and visitors to slip and fall from the water on the floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a quality living environment for one of the four sampled residents (Resident 1) when Resident 1 was placed in a bed in front of a flood-prone exit door. This deficient practice resulted in Resident 1's clothing becoming wet and had the potential for unnecessary damage to her clothing, which could cause emotional distress to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide toileting hygiene care after a bowel movement for one of three sampled residents (Resident 25). This failure had the potential to result in Resident 25 developing further skin breakdown.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 2) was free from mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation). 2. Implement the facility Policy and Procedure (P&P) titled Abuse: Prevention of and Prohibition Against revised 12/2023, that indicated each resident had the right to be free of abuse. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident who had a suspected deep tissue pressure injury (SDTI, suspected pressure injury where damage is occurring beneath the skin, but the surface skin may still appear intact. It's characterized by a purple or maroon localized area of discolored skin or a blood-filled blister due to damage to underlying soft tissues from pressure) to a right heel and left heel blister did not progress to unstageable (actual pressure injury covered by slough [(pale yellow, thick, tissue with fiber) and/or eschar [a piece of dead tissue that is cast off from the surface of the skin] pressure injury for one of 16 sampled residents (Resident 35). The facility failed to: 1. Ensure Resident 35's right heel SDTI did not decline to an unstageable pressure injury2. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for three of five sampled residents (Resident 40, 4, and 34) with ROM and mobility concerns by failing to: 1. Provide Resident 40 with a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) screening or evaluation in accordance with the PT Job Description when the facility identified Resident 40's decline in ability to perform sit-to-stand (ability to come to a standing position from sitting) transfers on 10/4/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the protection and promotion of Resident Rights for one of six sampled residents (Resident 21) by not covering Resident 21's genital area and failing to close the privacy curtain during care. This failure had the potential to result in residents not being treated with dignity and respect, not receiving care in a manner that promotes quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 22 and 325) had Interdisciplinary Team (IDT: group of professionals from different departments coordinate care and address the multifaceted needs of resident) meetings to discuss plan of care and discharge goals. This deficient practice had the potential to violate Resident 22 and 325's right to be an active participant in their plan of care and delay the services needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 22 and 325) had Interdisciplinary Team (IDT: group of professionals from different departments coordinate care and address the multifaceted needs of resident) meetings to discuss plan of care and discharge goals. This deficient practice had the potential to violate Resident 22 and 325's right to be an active participant in their plan of care and delay the services needed.

Inspectors wroteBased on interview and record review, the facility failed to obtain a resident's Advance Directive (AD-a written document that tells your health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself) upon admission for one of the four sampled residents (Resident 10). This deficient practice had the potential to cause conflict with the residents' wishes regarding health care decisions in cases where they are unable to make decisions for themselves.

Inspectors wrote(Cross Reference F686 and F726) Based on observation, interview, and record review, the facility failed to notify the responsible parties, and the physician of a change of condition (COC) for two out of 16 sampled residents. The facility failed to inform: a. Resident 35's physician of a COC when Resident 35's left foot suspected deep tissue injury (SDTI, a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. It typically results from sustained pressure or shear forces that compromise blood flow, leading to subsequent tissue necrosis. Recognizing a suspected deep tissue injury is crucial for timely intervention to prevent progression to more severe wounds) was noted to have a foul (bad) odor, an area of eschar (dead tissue that is hard or soft in texture; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans for three of 11 sampled residents (Resident 35, Resident 52 and Resident 57) when: a. Resident 35's care plan titled Has actual impairment to skin integrity related to (r/t) left heel blister (a painful skin condition where fluid fills a space between layers of skin)initiated [DATE] was not updated until [DATE] to indicate Resident 35 had a left heel suspected deep tissue pressure injury (SDTI, a form of unrelieved pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. It typically results from sustained pressure or shear forces that compromise blood flow, leading to ischemia and subsequent tissue necrosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the following were completed for two of three sampled residents: a. Resident 57 was seen by a neurologist as ordered b. Resident 63's decision making capacity was determined. This failure resulted in Resident 57 not being assessed by a neurologist potentially missing diagnostic test or services and Resident 63 potentially losing their right to make their own health care decisions and/or delaying care or treatment.

Inspectors wroteBased on interview, and record review the facility failed to ensure facility staff were competent when caring for two out of 16 sampled residents (Resident 35 and Resident 57) with pressure injuries (areas of damaged skin and tissue caused by sustained pressure) by failing to: a. Ensure treatment nurse (TXN 1) was competent in performing and documenting weekly wound assessments per the facility's Wound Management and Prevention Policy and Procedure (P/P) for Resident 35. b. Ensure TXN 1 was competent in completing a change of condition (COC) assessment and notifying the physician when a change in Resident 35's left heel suspected deep tissue pressure injury (SDTI, a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide social services to two (2) out of four sampled residents (Resident 15 and 325) by failing to assess the resident's psychosocial needs and trauma screening upon admission. This deficient practice had the potential for delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services that meet the needs of its residents, as evidenced by: 1. Failed to keep a separate record of emergency drug usage for drugs retrieved from the Cubex (a computer-controlled system that automates drug dispensing in a health facility). 2. Failed to ensure there were signatures of the licensed nurses who witnessed the non-controlled drugs disposition performed on 3/13/25. 3. Failed to ensure nurses checked the medications against the orders for accuracy when receiving medication delivered by the pharmacy, for Residents 377 and 429. (See also F-759, 760) 4. Failed to ensure nurses would consult with MD for an order to crush medications before crushing medications (Resident 67). These deficient practices had the potential for medication errors, adverse effects, and drug diversion.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure its medication error rate was less than five (5) percents (%). Three medication errors out of 31 total opportunities yielded a medication error rate of 9.68%, in 2 of 4 sampled residents (Residents 429 and 377) observed during medication administration (med pass). This deficient practice of med pass error rate at 9.68% exceeded the 5 % threshold and had the potential of adversely affecting residents' health condition.

Inspectors wrote(refer to F-755 and 759) Based on observation, interview, and record review, the facility failed to ensure two (2) of 4 sampled residents (Residents 377 and 429) were free of significant medication errors. The facility failed to ensure: 1. Resident 377 received morphine sulfate (a potent opioid for pain management) ER (extended release, release drug slowly into the body over an extended period of time) tablet 15 milligrams (mg, unit to measure mass) as per order; instead, Resident 377 received morphine sulfate immediate release (IR, release drug into the body right away). 2. Resident 429 received benazepril (generic for Lotensin, a type of medication to treat high blood pressure) 20 mg as per ordered. Instead, Resident 429 received benazepril 40 mg. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes and portion sizes for lunch menu was followed on 4/15/25 when: 1.cook used small scoop size to serve Barbeque (BBQ) chicken for residents who were on ground texture modified diet. Four residents on ground texture diet received 2 2/3 ounces (oz.) of chicken instead of 3 oz. per the menu. 2.15 residents on mechanical soft diet (diet for residents who experience chewing or swallowing limitations, food texture is modified by chopping or grinding), received bbq chicken cut into inconsistent sizes instead of ground bbq chicken per menu and spreadsheet (food portion and serving guide) 3. Facility failed to ensure staff followed food production recipes for the puree diet (food that is blended to a pudding consistency, no chewing required). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. follow transmission-based precautions (TBP) for one of three sampled residents (Resident 64) in contact isolation for clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea), b. follow enhanced barrier precautions (EBP) and indwelling catheter (type of flexible tube which a clinician passes through the urethra and into the bladder to drain urine) was not touching the floor for one of three sampled residents (Resident 70), and c. report an outbreak of C.diff to the local and state health departments. This failure had the potential to prevent an outbreak from spreading and transmit infectious diseases placing all residents at an increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the immunization status for the Influenza (flu: a contagious respiratory illness) and Pneumococcal (PC: bacterial infection that causes serious lung infections) vaccinations (medication to prevent a particular disease) for two of five sampled residents (Resident 12 and 49). This deficient practice resulted in Resident 12 and 49's incomplete medical records.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of facility employees' screening, education, offering (vaccination), and current Corona virus disease, ([COVID-19] a highly contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This deficient practice had the potential to place the facility staff and residents at risk for outcomes such as severe pneumonia (inflammation of lungs that cause difficulty breathing) which could lead to hospitalization due to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to report immediately and not later than twenty-four hours after receiving an allegation of abuse to the state agency as indicated in the facility's policy and procedure (P/P) for one of six sampled residents (Resident 2). As a result of this deficient practice Resident 2 had the potential to experience additional mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) from Resident 2's alleged abuser, family member (FM) 4 causing Resident 2 increased anxiety (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). (cross reference F600 and F610)

Inspectors wroteBased on interview and record review, the facility failed investigate an allegation of abuse as indicated in the facility's policy and procedure (P/P) for one of six sampled residents (Resident 2). As a result of this deficient practice Resident 2 had the potential to experience additional mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) from Resident 2's alleged abuser, family member (FM) 4 causing Resident 2 increased anxiety (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). (cross reference F600 and F609)

Inspectors wroteBased on interview and record review, the facility failed to complete a written bed-hold form upon transferring for one of three sampled closed record review residents (Resident 72). This deficient practice had a potential to result in placing the residents at risk for not knowing their rights and not being able to return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Falling Star Program, dated 3/20/2024, that indicated, if the resident has fallen in the last 30days, staff would place a falling star sticker on their door tag to ensure one of one sampled resident (Resident 11) remained free of accident by not placing a star sticker on resident's door post. Resident 11 had four times falls in the past four months. This failure had the potential for Resident 11 to sustain injuries from falling, due to lack of proper supervision that would be indicated by a falling star sticker.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) titled, Oxygen, Use of, revised 5/2021, that indicated, the oxygen cannula or mask, and the disposable humidifier would be changed at least every seven days, by not replacing the nasal canula after being used more than seven days for one of one sampled resident (Resident 52). This failure has the potential to compromise the resident's safety and well-being and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician face-to-face visit was made by a physician at least once every 60 days for one of three sampled residents (Resident 49). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 52) was free of unnecessary psychotropic medicine (any drug that affects brain activities associated with mental processes and behavior) by failing to ensure there was evidence of non-pharmacological intervention or evaluation of environmental triggers for resident 52's routine use of temazepam (generic for Restoril, a hypnotic/psychotropic used to aid in sleeping) for inability to sleep. This deficient practice had the potential to place Resident 52 at risk for using psychotropic medicine for excessive duration which could lead to the development of adverse effects and/or dependency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 24 sampled resident (Resident 44) food preferences were honored when strawberry Flavored Gelatin was placed on Resident 44's lunch tray, despite Strawberry being listed as a allergy and disklike on Resident 44's meal tray ticket. This failure had the potential to result in decreased meal satisfaction and consumption and negatively affect Resident 44 nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 40) with range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) concerns had complete and accurate medical records by failing to: 1. Accurately indicate the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) providing Resident 40's RNA services for active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms and legs and sit to stand transfers (ability to come to a standing position from sitting) on 7/2/2024, 7/3/2024, 7/4/2024, 7/15/2024, 7/16/2024, 7/17/2024, 7/18/2024, 7/22/2024, and 7/25/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA: committee that focuses on identifying and addressing quality deficiencies in resident care) failed to ensure effective oversight of the facility and implementation of their Quality Assurance and Performance Improvement (QAPI: systemic approach to improve the quality of care and services provided to residents) plan. This deficient practice had the potential to have reoccurring deficient practices that can impact the quality of care for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two (2) of 75 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room. This deficient practice had the potential to result in inadequate space to provide privacy, space during daily care, and access during an emergency.

Inspectors wroteBased on observation, interview and record review, Licensed Vocational Nurse (LVN) 1 failed to administer medication on time in accordance with written orders of the attending physician for five of five reviewed residents This deficient practice of failing to administer medications in accordance with the physician orders increased the risk of Residents 1,2, 3,5, and 6 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to label with an open date, when a multi-dose vial of Humulin N (a medication that lowers levels of glucose-sugar in the blood to manage diabetes mellitus-DM - high blood sugar) 100 IU vial (10 milliliter [ml-unit of measurement]) was opened, in medication cart #2. This deficient practice had the potential for loss of efficacy of residents' insulin, had the potential for unintentional medication administration of possibly expired medications for residents.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN 2) failed to take off used gloves and wash hands after performing blood sugar check to resident. This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan was: 1. implemented for 1 of 3 sampled residents (Resident 114) when nursing staff assist Resident 114 with fracture of the fourth thoracic vertebrae (upper back) during her turning and repositioning in bed), 2. revised for 1 of 3 sampled residents (Resident 115) to include a dialysis emergency kit (E-Kit- supplies including gauze, tape and clamp used to stop bleeding) in Resident 115's interventions to address possible bleeding emergencies. 3. formulated for 1 of 3 sampled residents (Resident 53) who was prescribed and taking a medication Plavix (a medication used to prevent clots forming in the blood vessels to prevent a stroke, heart attack or death, with prolonged and excessive bleeding as an adverse or side effect). [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to: 1. Properly store lentils and black beans according to the facility's policy and procedure. 2. Properly place thawing meat such as fish and chicken appropriately in the refrigerator when the thawing fish was placed on top of hard-boiled eggs and raw vegetables were placed next to thawing chicken. These deficient practices have the potential to place 62 residents who are served food from the facility's kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 164 and Resident 2) were free from risk of contracting infection when: a. the facility failed to properly store one of one sampled resident's (Resident 164) oxygen tubing (a device that provides additional oxygen through the nose) when Resident 164's oxygen tubing was found on the floor. b. Resident 2's foley catheter (a tube that is inserted into the bladder, allowing the urine to drain freely into a collection bag, which must be strapped and/ or secured) was not secured to prevent from touching the floor. These deficient practices have the potential to spread germs and bacteria from the floor to Resident 164 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program policy for three of three sampled residents (Resident 27, 59 and 164) by not completing the McGreer's Criteria (criteria used to determine appropriate use of antibiotics). This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call lights of two of two sampled residents (Resident 53 and Resident 42) were fixed in a timely manner. This failure has the potential for delay of care and services to Resident 53 and Resident 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 27 and Resident 116) received care consistent with standards of practice by failing to: A. monitor Residents 116's left upper extremity for skin breakdown per care plan and physician orders. B. monitor Resident 27 for the side effects of Aspirin (medication to thin blood) consistent with the facility policy. These deficient practices: A. resulted in a delay in care and services for Resident 116, whose wound on the left upper extremity was not assessed and not treated for approximately six hours leading to discomfort and risk or skin infections. B. resulted in a lack of assessment for Resident 27 and the potential to cause a delay in needed services.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents maintain their function and joint mobility) program for one of three sampled residents (Resident 10) when RNA was provided four times a week instead of five times a week as per the physician order. This deficient practice had a potential to place Resident 10 at risk for a decline in range of motion (ROM).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 47) medication regimen review (MRR-) thorough evaluation of the medication regimen of a resident) order clarification for Ibuprofen (medication is used to treat pain) to be given with food was acted upon. This deficient practice had the potential to result in Resident 47 experiencing side effects of being administered Ibuprofen (Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are widely used to relieve pain, reduce inflammation, and bring down a high temperature.) on an empty stomach.

Inspectors wroteBased on interview and record review, the facility staff failed to maintain an accurate documentation of Restorative Nursing Assistant (RNA- nursing aide program that helps residents maintain their function and joint mobility) weekly progress report for one of two sampled residents (Resident 48) when the report dated 4/10/2024 was not complete. This deficient practice placed Resident 48 at risk for a decline or improvement in RNA progress to go undocumented.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary drugs by failing to: 1. Obtain an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for the use of a psychotropic medication (drug that affects brain activities associated with mental processes and behavior) for depression (persistent sadness and a lack of interest or pleasure)per the facility's policy and procedure (P&P). 2. Implement a care plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments) for depression per facility's P&P.