Shoreside Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not document a prescribed order for oxygen therapy on time and did not ensure oxygen therapy was delivered as prescribed for one (Resident #23) out of one sample resident who has a primary diagnosis of Chronic Obstructive Pulmonary Disease. This was evidenced by the absence of a written order for oxygen therapy in the Electronic Medication Administration Records (EMAR). During an initial screening observation on 09/23/2025 at 8:30 AM, revealed Resident #23 in bed with eyes closed, receiving oxygen at two liters per minute (Lpm) via nasal cannula (NC); the oxygen tubing was positioned on the resident's forehead. At 8:34 AM, the surveyor requested Registered Nurse (RN) Staff A to come to the resident's room. [...]

Inspectors wroteOn 06/04/24 at 9:11 AM. During medication administration observation was done on nursing unit C with Staff D, Licensed Practical Nurse, (LPN) using medication cart number one. During the medication administration observation Staff D, LPN walked away from the medication cart number one and entered a resident's room, leaving the computer screen open and resident's personal information visible. On 06/04/24 at 9:15 AM Staff D, LPN returned to medication cart number one and stated to surveyor, I made a mistake. I am supposed to close the computer screen whenever I leave the cart. I didn't close the screen because I forgot. Based on observation and interview the facility failed to ensure residents' confidential medical records were secure. [...]

Inspectors wroteBased on observation and interview the facility failed to follow the facility's policy regarding pharmacy procedures. As evidenced by during medication administration observation on Unit C, Licensed Practical Nurse (Staff A) administered an incorrect dosage of insulin to Resident #87. There were two residents that receive routine insulin residing on Unit C.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five (5) percent or greater. As evidenced by during medication administration observations an incorrect dose of insulin was given to Resident #87 and Resident #97 did not receive a prescribed injection for Anemia. There were 136 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was sufficient dietary staff in place to carry out the functions of the food and nutrition service department. There was only one dietary aide and one cook in the kitchen preparing breakfast. The deficient practice resulted in breakfast being delivered to the nursing units more than 30 minutes late. This has the potential to affect one hundred and twenty three residents out of one hundred and thirty seven residents who eat orally residing in the facility.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that include: failure to hold foods at regulatory temperatures, failure to clean and sanitize food preparation equipment after each use, failed to properly cover trash/garbage receptacle, failure to ensure cleaning cloth buckets have sufficient chemical levels, ensure that foods are thawed by regulatory regulations, failure to date and label all opened food containers, failure to eliminate dented food cans, and failure to handle clean silverware in a sanitary manor.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide 37 residents with reasonable accommodations for food preferences. there were 132 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 4 residential units (100 Unit, 200 Unit, 300 Unit and 400 Unit), in-house dialysis room, and laundry area.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure residents residing on the 300 Unit remained free of potential accident hazards from unsafe hot water temperatures in resident rooms and common shower areas.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow physician ordered High Calorie/High Protein Diet (Fortified/Enhanced Foods) for 18 residents out of 18 that included 6 sampled residents (Resident #24, Resident #39, Resident #78, Resident #89, Resident #102, and Resident #122) failure to follow physician ordered Fluid Restriction for 1 of 2 (Resident #49), and failed to provide physician ordered supplements for weight loss for 51 residents ( Resident #63, Resident #68, Resident #83, and Resident #106).

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to provide a safe sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide showers per resident preferences for three sampled residents reviewed for showers (Resident #38, Resident 83, and Resident #110).

Inspectors wroteBased on interviews and record reviews the facility failed to update the code status for 1 resident out of 3 sampled residents (Resident #106).

Inspectors wroteBased on observations, interviews, and record review the facility failed to secure the confidentiality of medical information for residents receiving dialysis for 10 (Resident #40, Resident #53, Resident #92, Resident #100, Resident #107, Resident #118, Resident #177, Resident #330, and Resident #424) out of 10 residents with dialysis services and the facility failed to secure the confidentiality of medical information for a resident receiving podiatry services (Resident #100).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide fingernail care for 5 out of 6 residents reviewed for Activity of Daily Living (ADL) care (Residents #79, Residents#112, Residents#39, Residents#68, Residents #110).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate nutrition for tube feeding for 1 of 4 residents reviewed for tube feedings (Resident #177).

Inspectors wroteBased on observations, interviews and record review, the facility failed to obtain an order and document use of oxygen or changing of oxygen tubing (Resident #43) and failed to date oxygen tubing and place signage for Oxygen in Use outside of resident's room (Resident #326), for 2 of 3 residents reviewed for Respiratory therapy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to secure medications at the bedside for 2 of 39 sampled residents (Resident #49 and Resident 424), and facility failed to secure medications and supplies in the unlocked, unattended inpatient dialysis room.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide nourishing meals on dialysis days for 1 of 3 residents reviewed for dialysis (Resident #49).