Hannah B G Shaw Home

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) to prevent cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one Resident (#2), out of a total sample of 15 residents, to ensure the Resident was free from physical restraints. Specifically, Resident #2's wheelchair was replaced with a Broda positioning wheelchair which no longer allowed the Resident to self-propel about the unit.

Inspectors wroteBased on record review and interview, for one Resident (#2), out of a total sample of 15 residents, the facility failed to develop a plan of care accounting for the Resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization.

Inspectors wroteBased on records reviewed and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#26) from a total sample of 15 residents. Specifically, the facility failed to ensure respiratory equipment including oxygen tubing and bilevel positive airway pressure (bipap-medical device used to treat breathing disorders) equipment was properly maintained and stored in a clean and sanitary manner to decrease the risk of potential contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and other opportunistic waterborne pathogens.

Inspectors wroteBased on observation and interviews, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents residing on one Unit (Memory Care), out of six units in the facility. Specifically, the facility failed to ensure staff implemented facility sponsored group activities for all residents on the Memory Care unit designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit (Memory Care Unit) of six units in the facility. Specifically, the facility failed to ensure a three-tiered cart with hazardous items stored on it was not easily accessible to wandering residents on a Dementia Special Care Unit.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure sufficient staffing levels were maintained to safely and adequately meet each resident's needs on all shifts every day on one (Memory Care) of three units in the facility.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed for three Residents (#57, #270, and #6), of 17 sampled residents, to ensure safe storage of medications and biologicals according to current standards of practice.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was properly stored, labeled, and dated in the main kitchen; and 2. Ensure food was properly stored, labeled, and dated in five of five kitchenettes.

Inspectors wroteBased on interviews and review of grievance documentation, the facility failed to formulate written grievances, follow up, and provide resolution for two Resident's Representatives who voiced grievances. Specifically, 1. Resident #48's Representative voiced concerns to the Administrator regarding resident safety due to low staffing on the Memory Care Unit and the frequent non-functioning of a doorbell outside the unit that alerts staff to unlock the door when someone wishes to gain access to the unit to see their loved one; and 2. Resident #45's Representative voiced concerns to the Administrator regarding resident safety due to low staffing on the Memory Care Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#43), out of a total sample of 17 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address the Resident's behavior of eating non-food items.

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to implement interventions timely after significant weight loss was identified for one Resident (#20), out of a total sample of 17 residents. Specifically, the facility failed to: -assess and evaluate the Resident's nutritional status, and -consider interventions to curb further weight loss, resulting in additional weight loss over a period of two weeks.

Inspectors wroteBased on records reviewed and interviews, for one Resident (#20), out of 17 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated. Specifically, the facility failed to ensure Resident #20 was seen by a physician within the first 90 days of admission.