The Shoal

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents have the right to dignified existence, self-determination for 1 of 6 residents (Resident #20) reviewed for dignity. RN V failed to knock, identify themselves before entering Resident #20's room. This failure could cause loss of privacy, decreased sense of safety for residents, and potential psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 (Resident #4) of 2 resident reviewed for gastrostomy tubes (a surgically implanted tube into the stomach to provide delivery of nutrition). RN A failed to check for placement of gastrostomy tube (g-tube) prior to administering medication. This failure could place residents with g-tubes at risk of complications such as aspiration, abdominal injury, tube dislodgement and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents had the right to be free from abuse for 1 (Resident #84) of 5 residents reviewed for abuse. The facility failed to ensure that Resident #84 from was free from mental abuse, verbal abuse, and deprivation of services by staff when CNA K verbally abused Resident #84 on 4/23/25 and placed his call light out of his reach. The failure could place residents at risk of mental abuse, verbal abuse, and deprivation of services by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 (Resident #84) of 5 residents reviewed for respect and dignity . The facility failed to provide Resident #84 privacy when providing incontinence care on 4/23/25 as the door to the room was open and the privacy curtains were not pulled. The failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected resident's status for 1 (Resident #22) of the 6 residents reviewed for accuracy of assessments. Resident # 22's assessment did reflect her hearing loss on section B0200 hearing inadequate on, quarterly, and annual assessment since admission date 9/22/2017 and readmission date 01/01/2018 This deficient practice could affect residents at the facility by contributing to inadequate care based on inaccurate assessments.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities, for 1 (Resident #22) of the 6 residents reviewed for the use of assistive device in that- Resident #22 was not assessed and did not receive care for her hearing deficit. This failure could place residents at risk of not receiving appropriate care and services needed to maintain their health and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility must include the expiration date when applicable for one (#100 Hallway medication aide medication cart) out of four medications carts reviewed for labeling of drugs. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma (eye condition that damages the optic nerve) and other causes of high pressure inside the eye) were labeled with expiration date on all medication carts. This failure could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 (Resident #84) of 5 residents that were reviewed for infection control practices. The facility failed to ensure that CNA K followed proper infection control while providing care to Resident #84 on 4/23/25. The failure could place residents at risk of infection, decline in health, or cross contamination.

Inspectors wroteBased on Observation, interview and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment for 3 (Resident #11, #29, & #50) of 18 residents reviewed for comprehensive assessment. 1 The facility failed to accuretly assess Resident #11's lack of teeth and no dentures. 2 The facility failed to accurately assess Resident # 29 for her hearing deficit. 3 The facility failed to accurately assess Resident #50 for his oral cavity. These failures could place the residents at risk of not having all medical needs assessed and met.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired food products was not used in food preparation and served to resident. The facility failed to ensure that dented cans of food were stored separately. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease.

Inspectors wroteBased on interview and record review the facility failed to complete and transmit an MDS for 1 of 3 (CR #90) residents reviewed for closed records. The facility failed to complete and transmit a discharge MDS for CR #90 This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the comprehensive care plan was completed and reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 96). --Resident # 96 comprehensive care plan was not completed by the review date and did not contain goals and interventions as coded in the baseline care plan. This failure placed residents at risk of not receiving proper care and services according to their individual status.