Shores Nursing and Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained prior to the administration of psychotropic medications for 2 of 6 residents reviewed for psychotropic medication use. (Residents #4 and #11)

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for 2 of 2 sampled resident reviewed for PASARR. (Resident #8 and #22)

Inspectors wroteBased upon interviews and record review, the facility failed to ensure adequate monitoring for behaviors and side effects were documented for 3 out of 6 residents reviewed. (Resident #1, #4, and #11). 1. On 8/12/26, a chart review for Resident #1 revealed an admission date of 7/4/25 with diagnoses including dementia, seizure disorder, psychotic disorder, anxiety disorder, and depression. Resident #1's physician prescribed the psychotropic medications Olanzapine Oral Tablet 20 mg, 1 tablet by mouth at bedtime for restlessness, agitation, generalized anxiety disorder, and depression; Haloperidol Oral Tablet 10 mg, 1 tablet by mouth three times daily for intermittent explosive disorder; and Ativan Oral Tablet 0.5 mg, 1 tablet by mouth three times daily for anxiety. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure adequate assessment and implementation of smoking safety interventions to reduce the risk of accidents and injury associated with smoking for 4 of 4 sampled residents for smoking safety. (Residents #12, #85, #52 and #11)

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. 28 medication opportunities were observed with 3 errors occurring, for a total medication error rate of 10.71 percent.

Inspectors wroteBased upon observation, interview and review of facility policy, the facility failed to ensure medications were stored in a locked secure manner.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in 7 of 60 rooms. (rooms 341, 342, 343, 344, 345, 346, 347) The findings Include: On 08/10/2026 at 12:25 PM, during an observation of the 300 Hall, the resident bathrooms for Rooms 341-347 were observed to have black and dark-colored filmy growth on multiple surfaces, including the bathroom ceilings, walls, doors, and door frames. The bathroom environments were observed to be warm and had a musty and foul odor. (Photographic evidence obtained) On 08/11/2026 at 8:45 AM, 8/12/2026 at 8:51 AM and 1:33 PM, and 8/13/2026 at 9:03 AM, follow-up observations of the bathrooms associated with Rooms 341 - 347 revealed the black/dark growth remained present on the ceilings, walls, doors, and/or door frames. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to provide an environment that is free of offensive odors and failed to maintain a sanitary and clean environment in 7 of 15 rooms on the 300 unit and 8 of15 rooms on the 400 unit. (Rooms identified are 341, 342, 348, 352, 353, 354, 355, 456,461,464, 466, 467, 468, 469, 470, including the patio outside the 400 unit.)

Inspectors wroteBased upon interviews and record reviews, the facility failed to notify state and federal agencies of an incident involving elopement of a resident from the facility for 1 of 2 residents reviewed for elopement. (Resident #5)

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the necessary care and services to maintain grooming and incontinence care for 1 of 2 residents sampled for incontinence care (Resident #7).

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents in the 400 Hall Memory Care Unit lived in a clean, comfortable, homelike environment.

Inspectors wroteBased on resident council interviews, review of resident council grievances, staff interviews, and policy reviews, the facility failed to demonstrate acting upon 1 of 1 sampled grievances filed by the resident council regarding food.

Inspectors wroteBased on observation, resident interviews, and staff interviews, the facility failed to maintain resident equipment in a safe and sanitary manner in 1 of 20 rooms. (room [ROOM NUMBER])

Inspectors wroteBased upon observations, record reviews, and interviews, the facility failed to provide a comprehensive person-centered care plan process to meet the needs and services for six out of twenty-one residents reviewed. (Residents #5, #10, #27, #79, #31, and #51)

Inspectors wroteBased upon observations, interviews and record reviews, the facility failed to meet the needs and services of resident number 27 who is unable to carry out activities of daily living.

Inspectors wroteBased upon observations, interviews and record review, the facility failed to provide care and services for 1 of 1 residents reviewed for range of motion (Resident #5).

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to provide appropriate care and services of an arteriovenous (AV) fistula for 1 of 1 sampled residents receiving dialysis services. (Resident #39)

Inspectors wroteBased on record review and staff interview, the facility failed to provide medication to prevent hepatic encephalopathy (swelling of brain caused by liver disease) as prescribed to Resident #31 who subsequently experienced a change in condition which required transfer to a hospital.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to provide documentation that 4 of 6 residents reviewed received education and were offered the pneumococcal immunization. (Resident #21, #76, #14, and #50)

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to provide documentation that 5 of 6 residents reviewed received education and were offered the pneumococcal immunization. (Resident #72, #21, #76, #14, and #50)

Inspectors wroteBased on observations and staff interview, the facility failed to ensure each resident's bedroom was equipped to provide full visual privacy for 2 of 20 sampled resident rooms. (Room numbers 219 and 220)

Inspectors wroteBased on record review and interview, the facility failed to ensure that employee performance reviews were completed every 12 months for 1 of 6 sampled Certified Nursing Assistant (CNA) staff members. (Staff Member D) Additionally, the facility failed to ensure that 1 of 6 staff members received annual training for responding to cognitively impaired residents with difficult behaviors every 12 months. (Staff Member D)

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to promote resident dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life for 9 of 32 sampled residents (#1, #5, #6, #8, #11, #14, #16, #18 and #31). The facility failed to allow 4 of 32 sampled residents to wear their own personal clothing (Residents #1, #6, #11, #14, #18), failed to provide enough clean clothes for 2 of 32 sampled residents (Residents #8, #16), and failed to allow 1 of 34 sampled residents to be out of his room at night (Resident #16).

Inspectors wroteBased on observation, resident interview, and staff interview, the failed to provide adequate supplies of clean laundry in 4 of 5 linen storage areas observed affecting 8 of 32 current residents sampled (#1, #5, #6, #8, #14, #16, #19, adn #21). The failure had the potential to affect all 92 residents residing at the facility.

Inspectors wroteBased on record review, resident interview, staff interview and staff, and grievance policy review, the facility failed to ensure the prompt resolution of grievances for 7 of 10 grievances sampled from May to July 2024 (Residents #4, #5, #14, #16, #28, #29, and #30). The facility failed to document a grievance reported by Resident #16 in July, and failed to document any investigation for grievances filed by Residents #4, #5, #14, #28, #29, and #30 in July 2024.

Inspectors wroteBased on observations, resident interview, staff interview, record review, and policy review. the facility failed to provide timely assistance to residents in a timely manner for 1 of 15 residents sampled residents for oral care (Resident #1), 1 of 15 residents sampled residents for nail care (Resident #1), 3 of 15 residents sampled residents for podiatry care (Resident #1, #6, and #16), and 15 of 15 residents sampled for assistance with hygiene. (Resident #1, #5, #6, #8, #9, #12, #16, #19, #20, #21, #24, #31, #32, #33, and #34)

Inspectors wroteBased on observations, resident interviews, staff interview, and record review, the facility failed to provide sufficient staff to provide for resident basic needs as required by the residents' care plans for 14 of 15 residents sampled for assistance with daily living (Resident #1, #5, #6, #8, #9, #12, #16, #19, #20, #24, #31, #32, #33 and #34). Interview conducted with 10 of 10 residents (#1, #5, #6, #8, #12, #16, #24, #31, #32 and #34) and 6 of 6 staff (Certified Nursing Assistant CNA E, F, G, Personal Care Assistant N, and nurses A and C) indicated insufficient staffing.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to develop a care plan for 1 of 3 residents sampled for wound care. (Resident #7)

Inspectors wroteBased on record review and interviews, the facility failed to obtain laboratory results for 1 of 1 residents sampled for blood sample testing. (Resident #7)

Inspectors wroteBased on observation of laundry storage and laundry procedures, staff interviews, review of the laundry policy, review of laundry training, and review of job descriptions, the facility Administration failed to provide oversight in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable level of well-being for all 68 residents in the facility. Administrative staff failed to ensure that essential equipment, washing machines, were in working order and facility textiles and resident clothes were stored, sorted, processed and transported in a manner to prevent cross-contamination in accordance with facility policy. The facility failed to ensure that the facility Infection Preventionist had oversight of the laundry procedures. [...]

Inspectors wroteBased on observation, staff interviews, resident interviews, and quality assurance performance improvement plan (QAPI) review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to ensuring an adequate supply of clean linens was readily available for resident use and care; ongoing housekeeping and maintenance issues throughout the facility; maintaining essential equipment (washing machines) in good operating order; and infection control processes and training related to laundry processing. Concerns were previously identified with clean linen availability, broken laundry equipment and the QAPI processes during a complaint investigation ending a year ago on 2/02/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11. Citations were issued at F584 (Environment) and F867 (QAPI). [...]

Inspectors wroteBased on observation of laundry storage and laundry procedures, staff interviews, review of facility laundry policy, facility laundry inservices, and a review of the Centers for Disease Control (CDC) guidelines, the facility failed to ensure that facility textiles and resident clothes were stored, sorted, processed and transported in a manner to prevent cross-contamination in accordance with facility policy and recommendations by the CDC. The facility failed to ensure that the facility's Infection Preventionist had oversight of the laundry procedures. The facility failed to update their laundry procedures to ensure hygienic laundry after both facility washing machines failed, and the facility made the determination to utilize a local laundromat. This failure had the potential to affect all 68 residents at the time of the survey. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, ombudsman interview, and review of facility provided documentation, the facility failed to maintain 2 of 2 laundry washing machines in good repair. Both of the facility washing machines have been non-functional since at least November 2023 (exact date could not be determined). The first washing machine became non-functional in the month of December 2022 (exact date could not be determined) and remained broken. Staff were unable to demonstrate the specific date the second washing machine broke. Invoices indicated that parts were ordered both in September 2023 and November 2023. Observations found a lack of readily available linens in 2 of 2 linen closets, resident beds with missing sheets and pillowcases, residents observed without a change of clothing in their closets, and residents wearing hospital gowns. [...]

Inspectors wroteBased on observation of laundry storage and laundry procedures, staff interviews, review of facility laundry policy, and facility laundry staff training, the facility failed to ensure that staff were trained in infection control processes related to the laundering of linens and resident clothing to prevent cross-contamination. Both of the facility laundry machines (2 of 2) have been non-functional since at least November 2023. Facility staff are transporting soiled laundry to a local laundromat for washing, then bringing the wet laundry back to dry. However, not all the wet laundry could be dried at once, so some of the clean wet laundry was stored wet, often overnight. The laundry was not being handled, stored, processed, or transported, in a manner to prevent the spread of infection. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, and clinical record review, the facility failed to implement the care plan for 2 of 2 sampled residents with Activity of Daily Living Care concerns (Resident #9 and #45). The facility identified that resident #9 needed extensive assistance with transfers, ambulation, dressing, toileting, and bathing. The facility failed to provide bathing in accordance with the resident's abilities and preferences. The facility failed to assist with ambulation (walking) and transfers out of bed since November 2023 for Resident #9. The resident was observed dressed in a hospital style gown. The facility failed to provide timely incontinence care for 12 hours the evening/night of 1/31/24 into the morning of 2/1/24. The morning of 2/1/24, during incontinence care, a new buttocks wound was discovered for Resident #9. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews and clinical record review, and the facility failed to provide necessary care and services to ensure that a resident maintains or improves abilities in activities of daily living (ADL) for 1 of 2 residents sampled for ADL care, #9. The facility failed to provide bathing and dressing assistance in accordance with the resident's abilities and preferences. The facility failed to assist with mobility (walking) and transfers out of bed since November 2023. During the survey, when the facility did assist resident #9 out of bed on 1/31/24, Resident #9 was left in a wheelchair for about 10 hours. The facility failed to provide timely incontinence care for 12 hours the evening/night of 1/31/24 and morning of 2/1/24. This failiure resulted in the discovery of a new buttocks wound on 2/1/24.

Inspectors wroteBased on observations, resident interviews, family interviews, staff interviews, room check documentation and the housekeeping job description, the facility failed to maintain a sanitary and orderly interior, and clean linens that were in good condition. The facility failed to provide adequate housekeeping services to ensure the daily cleaning of resident rooms throughout the facility. The lack of housekeeping services affected 13 of 26 sampled residents (#1, 2, 9, 10, 16, 19, 23, 30, 40, 45, 47, 54, and #211) plus 8 additional resident rooms (341, 343, 345, 347, 349, 351, 353, and 355), the shower rooms in the 100 and 200 hallways and the baseboards in the 300 hallway. This failure had the potential to affect all 68 residents at the time of the survey. For additional laundry related concerns, please cross reference F835, F867, F880, F908 and F945.

Inspectors wroteBased on staff interviews and record review of the payroll-based journal (PBJ) Staffing Data Reports for Quarter 3 and Quarter 4 2023, the facility failed to accurately submit staffing information to CMS (Centers for Medicare and Medicaid).

Inspectors wroteBased on record reviews, staff interviews, resident and family interviews, review of November 2023 medication training, and policy review, the facility failed to ensure procedures were in place and followed to assure the accurate administering of all drugs 5 of 21 residents sampled for Medication Administration Records (#9, #35 #45, #211 and #311 ).

Inspectors wroteBased on observation, resident interview, staff interview and review of the 2022 Food Code from the United States Public Health Service Food and Drug Administration, the facility failed to ensure chicken was thoroughly cooked the evening of 1/31/24. This affected 5 observed dinner trays, including the tray served to resident #9.

Inspectors wroteBased on resident interview, staff interview, review of Treatment Administration records (TAR), clinical record review, and review of staff training from November 2023, the facility failed to ensure accurate medical record documentation (TAR) for 2 of 21 residents sampled for Medication Administration Records (#9 and #211).

Inspectors wroteBased on staff interview, family interview, medical record review, and policy review, the facility failed to ensure residents had advance directives included in the medical record for 1 of 2 residents reviewed for advanced directives. (Resident #43)

Inspectors wroteBased on staff interview, family interview, medical record review, and policy review, the facility failed to develop an Advanced Directive Care Plan in accordance with the residents preferences for 1 of 2 residents reviewed for advanced directives. (Resident #59)

Inspectors wroteBased on resident interviews, staff interviews and record review, the facility failed to ensure that 1 of 1 sampled residents received assistance arranging services for evaluation and treatment of issues with vision (Resident #9).

Inspectors wroteBased on observations, staff interviews and review of the Director of Nursing (DON) job description, the facility failed to designate an acting DON when the facility DON was on extended leave.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to appropriately store medications.

Inspectors wroteBased on observations, resident and family interviews and staff interviews, the facility failed to maintain an effective pest control program.