Shaker Gardens Nursing and Rehabilitation Center

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, interviews, local police report review, hospital record review, and facility policy review, the facility failed to provide adequate supervision to prevent a resident, with altered mental status and a history of wandering behaviors, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death when on 05/26/26 at approximately 9:35 P.M., Resident #48 left the facility without staff knowledge and was later found by the local police approximately five miles away. This affected one resident (#48) of three residents reviewed for elopement. [...]

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure an adequate supply of washcloths and towels were available for resident care needs. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of five percent (%) or less. Five medication errors out of 27 observed opportunities for error, created a medication error rate of 18.5%. This affected two of three residents reviewed for medication administration (Resident #5 and #4). The total census was 48.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure fall interventions were in place for Resident #47. This affected one resident (#47) of three residents reviewed for falls. The facility census was 50. Findings Include: Review of Resident #47's medical record revealed an admission date of 06/07/23 and diagnoses including acute pulmonary edema, bipolar disorder, generalized anxiety disorder, hypertension, depression, dementia with other behavioral disturbance, and moderate protein calorie malnutrition. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was cognitively impaired and did not reject care. Resident #47 required substantial/partial assistance to sit to stand. Resident #47 could wheel 50 feet in her wheelchair with two turns with supervision or touching assistance. [...]

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure Resident #49 did not leave the facility without staff knowledge and did not ensure a safe discharge. This affected one resident (#49) of three residents reviewed for elopement. The facility census was 48.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the dumpsters and surrounding areas were maintained and free from trash and debris. This had the potential to affect all 42 residents currently residing in the facility.

Inspectors wroteBased on observations, staff interview, record review, review of facility infection control policies and the Centers for Disease Control and Prevention (CDC) website the facility failed to implement infection control procedures for Personal Protective Equipment (PPE). This had the potential to affect all 42 residents currently residing in the facility. The facility also failed to ensure tuberculosis (TB) testing was completed as required. This affected two (Residents #30 and #38) of five residents reviewed for TB testing.

Inspectors wroteBased on interview and review of resident accounts the facility failed to notify residents who receive Medicaid benefits when the amount in their account reached $200.00 less than the SSI (supplemental security income) resource limit for one person. This affected five (Residents #9, #17, #33, #36 and #91) of six residents whose accounts were reviewed of nine resident accounts the facility managed.

Inspectors wroteBased on observation, record review, staff interview, and policy review the facility failed to ensure serving sizes for vegetables were provided according to the menu. This had the potential to affect all residents except Residents #21, #24, #25, #139, and #190, who received nothing by mouth. The facility also failed to ensure serving sizes for the mechanical soft beef was served according to the menu. This had the potential to affect nine residents (#7, #10, #12, #18, #22, #29, #34, #189, and #239) who received a mechanical soft or ground diet. The facility census was 42.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure influenza and pneumonia vaccinations were completed as required. This affected four (Residents #30, #40, #191, and #192) of five residents (#30, #38, #40, #191, and #192) reviewed for influenza and pneumonia immunizations. The facility census was 42.

Inspectors wroteBased on record review and interview the facility failed to ensure residents' signed advance directive forms were contained in their medical record. This affected two (Residents #189 and #191) of two residents reviewed for advance directives. The facility census was 42.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to identify a reason for an immediate discharge. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to notify the resident and the resident's representative of a discharge. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure a resident was oriented and prepared for discharge from the facility. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized care plan for Resident #7's risk for skin breakdown or develop an individualized care plan for Resident #9's refusal of assessed contracture prevention devices and nail care. This affected two (Residents #7 and #9) of 20 residents whose care plans were reviewed (#2, #11, #15, #16, #22, #24, #25, #26, #29, #30, #31, #32, #38, #40, #139, #189, #191 and #192). The facility census was 42.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to obtain weights as ordered by the physician to ensure accurate assessment and treatment by the dietitian for a resident identified at nutritional risk. This affected one (Resident #24) out of three residents reviewed for nutritional related concerns. The facility census was 42.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% (percent). There were two medication errors of 30 medication administration opportunities resulting in a 6.66% medication error rate. This affected one resident (Resident #38) of six residents observed for medication administration.

Inspectors wroteBased on record review and staff interview the facility failed to ensure accurate documentation was completed for Resident #8 and Resident #3. This affected two residents (Resident #8 and Resident #3) of 26 residents whose records were reviewed. Findings Include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including dementia without behavioral disturbance, atrial fibrillation, and high blood pressure. Review of the Medicare 14 day Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident was severely cognitively impaired and had been admitted with two pressure ulcers. Review of Resident #8's skin grid notes dated 05/16/19 revealed the resident had a Stage III (a full thickness wound with full thickness tissue loss. [...]