Shorepointe Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (R3, R149, and R197), of five residents reviewed for dignity, were treated in a respectful, dignified manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meal set up for one resident (R53) of two reviewed for activities of daily living.

Inspectors wroteBased observation, interview, and record review the facility failed secure medications at beside for one (R152) sampled resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the resident's food preferences and ensure accuracy of their food ticket for one resident (R154) of one reviewed for food preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed for a catheter bag and nebulizer mask for two residents (R7 and R51) of two reviewed for infection control.

Inspectors wroteThis citation pertains to Intake: 2695258Based on observation, interview, and record review, the facility failed to prevent a fall for one resident (R901) of two residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meal portion sizes met the nutritional needs of the residents, resulting in the potential for inadequate protein intake, weight loss, and decreased meal enjoyment. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide person centered care plans for two sampled residents (R78 and R46) of three whose care plans were reviewed.

Inspectors wroteThis citation pertains to Intake MI00151407 and MI00151269. Based on observation, interview, and record review, the facility failed to respond to call lights and provide activities of daily living care (ADLs) in a timely manner for one resident (R152) and eight confidential group residents, of thirteen residents reviewed for ADLs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate amount of water flush was provided between administration of individual medications via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), for one resident (R73) of four observed during medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error of less than five percent for one resident (R73) of five residents reviewed for medication observation, resulting in a medication error rate of 12.82%.

Inspectors wroteThis citation pertains to Intake MI00152118. Based on observation, interview, and record review, the facility failed to ensure the blood pressure medication (Clonidine) for one resident (R73) of one resident reviewed was administered as needed per physician order

Inspectors wroteBased on observation, interview and record review, the facility failed to discard expired, label with resident identifier and date when opened biologicals in three of four medications carts and one of four medication rooms reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a tube feeding (TF) pole in a sanitary manner for one sampled resident (R128) of one reviewed for tube feeding sanitation. Findings Include: On 4/14/25 at 2:10 PM, R128 was observed lying in bed with their tube feeding in place noting a bag of Isosource 1.5 cal missing the resident's name, date, time, or order. The tube feeding pole and base were observed to have a very thick layer of brown dried tube feed stuck to it. Also noted were a pair of used gloves on the floor. A review of R128's medical record revealed they were admitted into the facility on 6/7/24 with diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Dysphagia, and Diabetes. Further review revealed the resident was severely cognitively impaired and was dependent on enteral feed for nutrition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call lights were in reach for three residents (R57, R106, R152) of four residents reviewed for call light accessibility.

Inspectors wroteThis citation pertains to Intake: MI00150544. Based on interview, and record review, the facility failed to protect one resident (R901) during an abuse investigation out of four residents reviewed for abuse resulting in fear of retaliation and feeling scared.

Inspectors wroteThis citation pertains to Intake: MI00150544. Based on interview, and record review, the facility failed to prevent staff misappropriation of resident funds (linking a gambling app and making withdrawals without resident consent from a joint bank account), for one sampled resident (R901) of four reviewed for abuse, resulting in an unauthorized withdrawal totaling $18,368.14.

Inspectors wroteThis citation pertains to Intake MI00149892. Based on interview and record review, the facility failed to ensure notification of a room change was provided for two residents (R906, R908) of three reviewed for room changes.

Inspectors wroteThis citation pertains to Intake M100149834: Based on interview and record review, the facility failed to implement care planned interventions to prevent a fall for one (R902) of three residents reviewed for falls.

Inspectors wroteThis citation pertains to Intake MI00146867. Based on observation, interview and record review, the facility failed to perform transfers according to the plan of care for one (Resident #4) of six reviewed.

Inspectors wroteThis citation pertains to Intakes: MI00145838, MI00146086, and MI00145914. Based on observation, interview, and record review, the facility failed to provide grooming and showers per schedule and preference for two residents (R701 and R714) out of three reviewed for Activities of Daily Living (ADLs).

Inspectors wroteThis citation pertains to Intake MI00145914. Based on observation, interview, and record review, the facility failed to set up a follow up appointment for one resident (R702) out of one reviewed for follow up appointments. Findings Include: A review of Intake MI00145914 noted the following, [R702] has an (indwelling) catheter (tube that goes into the bladder to drain urine) in and was supposed to get that out before coming here, however they only tried taking it out once and never tried to figure out why [they] needed it. On 8/8/2024 at 12:01 PM, R702 was observes sitting in their chair. R702 was noted to have a drainage bag for a catheter hanging on the side of their wheelchair. R702 stated they received the catheter in the hospital and the facility tried to take it out once, but put it back in. [...]

Inspectors wroteThis citation pertains to Intake MI00145880. Based on observation, interview, and record review, the facility failed to provide palatable hot meals for four of four residents interviewed. Additionally, meals were not provided according to the provided Tray Delivery Schedule.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate infection control practices were used for hand hygiene and equipment cleaning for five (R7, R30, R53, R127, R143) of five residents observed.

Inspectors wroteBased on interview and record review, the facility failed to provide a preadmission screening (PAS) and resident review (ARR) evaluation for one resident (R96) of three residents reviewed for PASARR, resulting in the potential for unmet mental health services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop, implement and update care planned pressure ulcer prevention interventions for two (R510 and R143) of four residents reviewed for care planning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals were labeled with a date opened and a resident identifier in three of five medications carts.

Inspectors wroteThis citation pertains to Intake: MI00142122. Based on interview and record review, the facility failed to revise interventions on the care plan following a fall for one resident (R901) of two residents reviewed for falls.