United Methodist Communities At The Shores

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 Resident #4's PASRR level one in the Electronic Medical Record (EMR) dated 11/2022 showed that section one of the PASRR asked if the resident had a mental illness was marked as no. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/29/25, reflected the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on Interview, record review, and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. The deficient practice was identified for 1 of 1 resident (Resident #45) investigated for Unnecessary Medications and was evidenced by the following: A review of Resident #45's admission Record reveale diagnoses of but not limited to; Cerebral Ischemia (blood flow reduced or blocked to the brain), Atherosclerosis Heart Disease (plaques build up in the arteries), Nonrheumatic Aortic Valve Stenosis, and Myocardial Infarction (heart attack). A review of Resident #45's Physician Orders (PO) dated 8/8/25 included: Eliquis Tablet 2.5 MG (milligrams), give 1 tablet by mouth two times a day for anticoagulated (blood thinner) that prevents blood from clotting, reducing the risk of blood clots forming in the arteries, veins, or heart. A review of Resident #45's Individual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to develop and implement a care plan that meets the medical needs identified on the comprehensive assessment care for 1 on 15 residents reviewed for comprehensive care plans related to an indwelling urinary catheter (tube inserted in the bladder to drain urine). (Resident #34.)This deficient practice was evidenced by the following: A review of Resident # 34's admissions record revealed that, Resident # 34 was admitted with but not limited to Retention of Urine (a condition where your bladder doesn't empty all the way or at all when you urinate), and heart failure. A review of the Resident #34's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident had an indwelling catheter. A review of the current Care Plan (CP) for Resident #34 did not include documentation of a CP focus area or interventions for the care of indwelling catheters. During an interview on 08/28/2025 at 09:13 AM with the surveyor the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter (tube inserted in the bladder to drain urine) drainage bag was secured in a manner to prevent contamination for 1 of 2 resident reviewed for a urinary catheter, (Resident #34). The deficient practice was evidenced by the following: During the initial tour of the unit on 08/26/2025 at 06:54 PM, Resident #34 was in bed with a Foley catheter drainage bag in contact with the floor, with privacy bag intact. It was not secured to the bed frame. A review of Resident # 34's admissions record revealed that, Resident # 34 was admitted with but not limited to Retention of Urine (a condition where your bladder doesn't empty all the way or at all when you urinate), and heart failure. A review of the Resident #34's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident had an indwelling catheter.During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 2/12/2024 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 1/9/2. 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. On a lower shelf in a previously opened card board box, a previously opened bag of pasta had no dates. The EC removed the pasta to the trash and agreed that the bag had no dates. In addition, on an upper shelf a previously opened container of Heinz tomato ketchup had dried ketchup covering the lid of the bottle. The EC agreed that it was dirty and could not identify when the bottle was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The Prednisone package had a red Cautionary label on the package from the pharmacy to take with food. There was no food observed in Resident #105's room and LPN #1 did not offer the resident any food. At that time the surveyor asked Resident #105 if he/she had eaten breakfast. Resident #105 replied, No. At that time the surveyor requested…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Four of the five residents stated that they were not offered evening snacks; however, they did state you can ask for anything and they will bring it to you. On 02/14/2024 at 12:33 PM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated that usually the aide will offer snacks to the residents, or the activity aide will do it before they leave for the night. When asked what time the snacks are given, CNA #1 replied she was not sure what time snacks are given. On 02/16/2024 at 01:04 PM, surveyor interviewed the Director of Nursing (DON), who stated that the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents (Resident #22, and Resident #43) reviewed for Beneficiary Protection Notification. This deficient practice was evidenced by the following: On 02/14/2024, the Administrator provided the surveyor with a list of residents who were discharged from the facility within the last six months and should have received Beneficiary Notices. The surveyor reviewed two of the residents (Resident #22, and Resident #43) listed who were discharged from a Medicare Part A (helps cover skilled nursing facility care including rehabilitation services) stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. On 02/16/2024 at 10:34 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #22. The SNFBPNR indicated the Resident #22's last covered Medicare day was 01/16/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 17 residents reviewed (Resident #29 and Resident #101). This deficient practice was evidenced by the following: 1. On 02/12/2024 at 11:10 AM, the surveyor observed Resident #29 out of bed in a wheelchair. The resident was first seen in the library. The nurse stated that the resident at times wanders to library. Resident was seen coming back into unit from library. Resident #29 was very pleasant and stated they were doing well. The surveyor review of Resident #29's admission record indicated that the resident was admitted with diagnoses that included, but were not limited to; a right hip fracture with surgical repair. A review of Resident #29's medical record indicated that on 11/09/2023, the resident was found on the floor by the window in the room. No injury was noted. A review of the Quarterly Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical needs and failed to implement focus and interventions that are specific to the resident's skin disorder diagnosis. The deficient practice was identified for 1 of 1 (Resident #21) investigated for positioning and mobility. The deficient practice was evidenced by the following: During the initial tour of the facility on 2/12/2024 at 10:29 AM, the surveyor observed Resident #21 sleeping in his/her geri chair in the unit hallway. Resident #21 was observed wearing bilateral heel protectors. On 2/14/2024 at 12:03 PM, the surveyor observed Resident #21 in the dining area in his/her geri chair waiting for lunch. Resident #21 was observed wearing bilateral heel protectors. According to the admission Record, Resident #21 was admitted to the facility with the following but not limited to diagnoses: Disorder of the skin and subcutaneous tissue, hypertension (high blood pressure),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain professional standards of nursing practice for not obtaining a physician's order. The deficient practice was identified for 1 of 1resident (Resident #21) investigated for positioning and mobility. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review of other facility documentation, it was determined that the facility failed to ensure 1 of 5 Certified Nursing Assistants (CNA #3) received 12 hours of required education annually. This deficient practice was evidenced by the following: The surveyor reviewed five (5) random CNA education files for the year 2023. A review of a transcript for CNA#3 titled, SYMPIR LEARNING, revealed the following: CNA #3 completed 10.75 hours. During an interview with the Nursing Staff Educator (NSE) on 02/14/2023 at 12:16 PM, she stated that the CNA was responsible to complete the yearly mandatory 12 hours of education to include both the Abuse training and the Dementia training. The NSE stated that she could not speak to why the CNA training was not completed. During an interview with the Licensed Nursing Home Administrator (LNHA) on 02/15/2024 at 11:43 AM, she stated that they are aware that the staff are not completing their yearly mandatory education and are reviewing their processes. A review of a facility policy titled, Clinical Staff Competency (RS-52) with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The DD stated, There are two other sinks available with soap. Surveyor asked if all sinks are to have soap available. The DD responded, Yes. 2. On the second shelf of the 2- Door Refrigerator an opened bag of parmesan cheese was wrapped in plastic wrap. The Parmesan cheese was dated 10/3/21 and 9/27/21. The DD was unable to determine an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined that the facility failed to detect and remove expired medication in 1 of 1 automated pharmacy dispensing units. This deficient practice was evidenced by the following: On 10/22/21 at 12:15 PM, the surveyor checked the automated pharmacy dispensing unit (APDU, a computerized storage device in which extra medication is stored for use in residents, where such medication is otherwise not available elsewhere). The surveyor observed the following, in the presence of the Registered Nurse (RN) and the Licensed Practical Nurse (LPN): eight capsules of expired Nitrofurantoin 50 milligrams (mg) (an antibiotic), all of which expired on 10/01/21; six tablets of Levofloxacin 250 mg (an antibiotic), all of which expired on 10/01/21; six capsules of Phenytoin 100 mg (an anti-seizure medication), all of which expired on 10/01/21; one bottle of 5 milliliters (ml) of Atropine Sulfate 1% (eyedrops used to dilate the eyes or decrease pain and inflammation), which expired 09/21; ten tablets of Cefpodoxime 100 mg (an antibiotic), all of which expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.