The Shoal

In the surveyor’s words

From the most serious findings on record at The Shoal, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 8, 2026

  Based on observation, interviewed and record review the facility failed to ensure that 1 of (Resident #67) 7 residents reviewed for abuse and neglect was free from neglect in that--Resident #67 was left outside at a dialysis center overnight without medications, incontinence care or food.-The facility failed to ensure that Resident #67 was transported from dialysis center.-The facility failed to follow up with Resident #67 when he did not return back to the facility.The noncompliance was identified as PNC IJ began on 07/03/26 and ended on 07/04/26. The facility had corrected the noncompliance before the investigation began on 07/09/26. […]

• Actual harm, isolatedF600Apr 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF636Feb 14, 2024

  Based 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. Findings included: 1.Record review of Resident # 11's electronic face sheet on 02/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF812Feb 14, 2024

  Based 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. Findings included: Observation and interview of the facility kitchen on [DATE] at 8:40 AM revealed the dietary Manager opened a 4 oz carton of milk to use in food preparation. Observation of the carton revealed a used by date of [DATE]. […]

• No harm, potential for more than minimal, patternF880Feb 11, 2022

  Based on observation, interview and record review the facility failed to 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 2 of 6 residents (Residents #3 and #5) reviewed for infection control. 1. The facility failed to ensure the ADON wore proper PPE when entering a resident's room who was positive for COVID-19. 2. The facility failed to ensure the DOR and NP wore proper PPE when entering a resident's room who was presumed positive for COVID-19. These failures could place residents' at risk of further spread of infection. Findings include: 1. […]