United Methodist Communities at the Shores

In the surveyor’s words

From the most serious findings on record at United Methodist Communities at the Shores, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 20, 2024

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 9:19 to 10:05 AM the surveyor, accompanied by the Executive Chef (EC), observed the following in the main kitchen: 1. On an upper shelf in the dry storage room a container of Ground Thyme was dated [DATE]. The surveyor asked the EC if the container of thyme was dated 2022,2023, or 2024. The EC could not tell the surveyor how old the thyme was or when it was placed on the shelf. The EC removed the thyme to the trash. […]

• No harm, potential for more than minimal, widespreadF812Nov 5, 2021

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/21/2021 from 9:55 AM to 10:47 AM the surveyors, accompanied by Dining Director (DD) and Executive Director (ED) observed the following in the kitchen: 1. At 10:31am, the surveyor attempted to wash his hands at the designated hand washing sink. Upon turning on the water, the surveyor attempted to apply soap from the wall mounted soap dispenser. The surveyor was unable to obtain soap. The DD opened the soap dispenser, and the dispenser was empty. […]

• No harm, potential for more than minimal, patternF759Feb 20, 2024

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure that all medications were administered without error rate of 5% or less. During medication pass observation on 02/14/2024, the surveyor observed one nurse administer medications to five residents. There were 26 opportunities and 2 errors which calculated to a medication administration error rate of 7.69%. This deficient practice was identified for 2 of 5 residents, (Resident #105 and Resident #106) and was evidenced by the following: On 02/14/2024 at 7:18 AM, the surveyor observed Licensed Practical Nurse (LPN #1) prepare and administer Prednisone (steroid medication) 20 mg (milligrams) po (by mouth) to resident #105. […]

• No harm, potential for more than minimal, patternF809Feb 20, 2024

  Based on interviews, and review of other facility documentation, it was determined that the facility failed to consistently offer nighttime snacks to all residents on a nightly basis. This deficient practice was identified for 4 of 5 residents (Residents #11, Resident #35, Resident #39, and Resident #251) during the Resident Council group meeting and was evidenced by the following: On 02/14/2024 at 10:15 AM, the surveyor conducted a group meeting with five residents who were selected by the facility. […]

• No harm, potential for more than minimal, isolatedF644Aug 29, 2025

  Based on interview and record review, it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment after a resident received a new mental illness diagnosis. This deficient practice was identified in 1 of 1 resident reviewed for PASRR (Resident #4) and was evidenced by the following:On 08/26/2025 at 7:06 PM, during the initial tour of the facility Resident #4 was in the room in bed.On 8/27/25 at 11:26 AM, the surveyor reviewed the medical Record for Resident #4.A review of the admission Record face sheet (an admission summary) reflected the resident was initially admitted to the facility with diagnoses which included but not limited to failure to pneumonia, bipolar disorder, muscle weakness, and chronic pain.A review of… […]