Shoreland Health Care and Retirement Center Inc

In the surveyor’s words

From the most serious findings on record at Shoreland Health Care and Retirement Center Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 24, 2022

  Based on record review, staff interviews and Nurse Practioner interview, the facility failed to perform cardiopulmonary resuscitation (CPR) while waiting for Emergency Medical Services (EMS) to arrive for 1 of 1 resident reviewed for CPR (Resident #205) who was observed by Nurse #7 to have no pulse and determined to have a full code status. Resident #205 was provided CPR by EMS and transported via EMS to the hospital where she was intubated and admitted to the intensive care unit. Findings included: A Cardiopulmonary Resuscitation (CPR) policy written [DATE] and revised in [DATE] stated, in part, it was the policy of this nursing facility to act affirmatively to preserve the life of all residents. […]

• Immediate jeopardy, isolatedF835Jun 24, 2022

  Based on record review and a staff interviews, the facility failed to provide oversight and leadership to ensure effective systems were implemented for staff to provide the necessary care and services by following the policy and procedure to call a code blue for a resident in [CONDITION(S)], to initiate Cardiopulmonary Resuscitation (CPR), to verify employed staff were current with their CPR certifications and failed to verify nurses who were present in the facility had a current CPR certification for 1 of 1 residents (Resident #205) reviewed for CPR. […]

• No harm, potential for more than minimal, widespreadF880Jun 24, 2022

  Based on observations, record review, and staff interviews, the facility failed to establish infection control policies, reports, testing procedures, to reduce the risk and growth and spread of Legionella in the building water systems that could affect 56 of 56 residents. Findings included: Review of the facility's Emergency Preparedness Plan and Water Safety Policy (effective 12/2021) revealed no information related to a facility water safety management program to minimize the risk of transmission of Legionella Disease (LD) to the residents, staff and visitors. In an interview on 06/23/22 at 1:30 PM. The Administrator stated she was unaware of the requirement to develop a program to minimize the risk of transmission of Legionella through the facility's water system. […]

• No harm, potential for more than minimal, patternF636Jun 24, 2022

  Based on record review and staff interviews the facility failed to 1) complete and transmit Minimum Data Set (MDS) admission assessments within the required timeframe for 2 of 9 residents (Resident #203, #1), 2) failed to complete a discharge with return anticipated assessment within the required timeframe for 1 of 9 residents (Resident #47) and 3) failed to complete a 14-day MDS assessment within the required timeframe for 1 of 9 residents reviewed for Resident Assessments (Resident #103). Findings included. 1) Resident #203 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review on 06/24/22 of Resident #203's admission assessment with the ARD (assessment reference date) of 05/18/22 revealed the assessment was incomplete and was in progress. […]

• No harm, potential for more than minimal, patternF638Jun 24, 2022

  Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14-calendar days of the Assessment Reference Date (ARD, the last day of the look-back period) for 5 of 9 residents reviewed for resident assessments (Resident #5, #6, #7, #8, and #12). Findings included: 1. Resident #5 was admitted to the facility on [DATE]. The most recent quarterly MDS assessment for Resident #5 was reviewed. The assessment had an ARD of 02/15/22 and a completion date of 05/18/22. In an interview conducted with the MDS Nurse on 06/21/22 at 4:00 PM she stated she had not been able to complete the MDS assessments on time, because she had been frequently assigned to work as a staff nurse. […]