Shoreline Healthcare Center

In the surveyor’s words

From the most serious findings on record at Shoreline Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 18, 2025

  Based on observation, interview and record review the facility failed to: 1.Ensure one out of six sampled residents (Resident 2) was free from mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation). 2.Implement the facility Policy and Procedure (P&P) titled Abuse: Prevention of and Prohibition Against revised 12/2023, that indicated each resident had the right to be free of abuse. […]

• Actual harm, isolatedF686Apr 18, 2025

  50144 Based on observation, interview and record review the facility failed to ensure the resident who had a suspected deep tissue pressure injury (SDTI, suspected pressure injury where damage is occurring beneath the skin, but the surface skin may still appear intact. It's characterized by a purple or maroon localized area of discolored skin or a blood-filled blister due to damage to underlying soft tissues from pressure) to a right heel and left heel blister did not progress to unstageable (actual pressure injury covered by slough [(pale yellow, thick, tissue with fiber) and/or eschar [a piece of dead tissue that is cast off from the surface of the skin] pressure injury for one of 16 sampled residents (Resident 35). The facility failed to: 1. […]

• Actual harm, isolatedF688Apr 18, 2025

  Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for three of five sampled residents (Resident 40, 4, and 34) with ROM and mobility concerns by failing to: 1. Provide Resident 40 with a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) screening or evaluation in accordance with the PT Job Description when the facility identified Resident 40's decline in ability to perform sit-to-stand (ability to come to a standing position from sitting) transfers on 10/4/2024. 2. […]

• Actual harm, isolatedF689May 19, 2023

  Based on interview and record review, the facility's nursing staff failed to ensure one of four sampled residents (Resident 1), who required an extensive two-person physical assist during toileting, was supervised while in the bathroom. CNA 2 left Resident 1 alone in the bathroom while she attended to another resident. Resident 1 became frustrated when no one came to his assistance, attempted to leave the bathroom, and fell from the shower chair As a result of Resident 1 falling from the shower chair he hit the floor causing pain to his back, right hip, and right leg. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was diagnosed with a fracture of the vertebrae (a series of small bones that form the backbone). […]

• Actual harm, isolatedF580Mar 26, 2021

  Based on observation, interview and record review, the facility failed to immediately inform and consult with the residents' physician when a resident experienced a significant change of condition ([COC] a clinical deviation from a resident's baseline) for two of 11 sampled residents (Residents 1 and 2) as follow: 1. On [DATE] at 4:30 a.m., Resident 1 first experienced a drop in oxygen saturation ([SPO2] a measure of how much oxygen the blood is carrying with normal reference range (NRR) being ,d+[DATE] percent [%]) of ,d+[DATE] % and required an increase need for oxygen (O2). 2. […]