Shaker Place Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Case #NY00377666), the facility did not ensure the residents' right to be free from abuse for one (1) (Resident #1) of one (1) resident reviewed for abuse. Specifically, on 4/09/2025 at 2:15 AM, Certified Nurse Aide #1 self-reported that they tapped Resident #1 on their right hand when the resident was combative during a shower. This is evidenced by: See cross references of F-609 and F-610. Resident #1 was admitted to the facility with diagnoses of anxiety disorder (mental health condition characterized by excessive fear or anxiety that interferes with daily activities), cognitive communication deficit (communication difficulties that arise from cognitive impairments), and insomnia (sleep disorder that can make it hard to fall asleep or stay asleep). [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Case #NY00377666), the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for one (1) (Resident #1) of one (1) resident reviewed. Specifically, Certified Nurse Aide #1 self-reported physical abuse to Resident #1 on 4/09/2025 at approximately 2:15 AM to Licensed Practical Nurse #1. The allegation was reported to the New York State Department of Health on 4/10/2025 at 10:33 AM. This is evidenced by: See cross references of F-609 and F-610. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Case # NY00377666), the facility did not ensure alleged violations of abuse were thoroughly investigated for one (1) (Resident #1) of one (1) resident reviewed for abuse. Specifically, Certified Nurse Aide #1 was not removed immediately from resident care when there was an allegation of physical abuse made on 4/09/2025, to prevent further abuse from occurring. Certified Nurse Aide #1 was allowed to finish their shift on 4/09/2025 and also worked 11:00 PM- 7:00 AM shift on 4/09/2025 into 4/10/2025. This is evidenced by: See cross references of F-600 and F-609. The facility Policy and Procedure titled, Abuse Prohibition Program, updated 12/2022, documented the facility should take necessary measures to protect residents from harm or potential abuse during any investigation of an allegation of abuse. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey and an abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure alleged violations of abuse, mistreatment, neglect, exploitation and misappropriation were thoroughly investigated, and did not immediately put effective measures in place to ensure that further misappropriation of resident property, abuse, neglect, or exploitation would not occur while an investigation was in process. Specifically on 11/26/2022, it was reported to the facility and the Police by Resident #188 and their Family Member (FM) #1 that the resident's credit card was missing, had unknown charges totaling approximately $10,000.00 since 05/2022, and were suspecting misappropriation by a staff member. Subsequently, this had the potential to affect all 235 residents within the facility. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey from [DATE] to [DATE], the facility did not ensure safe and appropriate labeling of all medications for 3 ([NAME] Unit, [NAME] Unit, and [NAME] Unit) of 3 units for medication labeling and storage. Specifically, the facility did not ensure insulin Kwik pens on the [NAME] Unit, [NAME] Unit, and [NAME] Unit were labeled with the date they were opened, and the expiration dates after opening. Also, the facility did not ensure nursing staff were knowledgeable regarding how to determine insulin expiration dates after opening. This is evidenced by: The Guardian Consulting Services (GCS) grid of Expiration Dates for Open Injectable Diabetic Medication pen expiration dates varied from discard after single use to 56 days, depending on type of insulin pen. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey and an abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure prompt efforts were made to resolve grievances for 1 (Resident #188) of 1 resident reviewed for grievances. Specifically, the facility did not ensure that complaints regarding Resident #188's missing personal property was acknowledged by the facility and necessary steps towards an appropriate resolution were taken. This is evidenced by: Resident #188: Resident #188 was admitted with diagnoses of major depressive disorder, morbid obesity, and atrial fibrillation (an irregular heart rhythm). The Minimum Data Set (MDS-an assessment tool) dated 11/14/2022 documented the resident was able to make themselves understood, could understand others, and was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, conducted during the recertification and abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure residents were free of abuse, neglect, exploitation, and misappropriation of resident property for 1 (Resident #188) of 14 residents reviewed for abuse, neglect, exploitation, and misappropriation of resident's property. Specifically, for Resident #188, the facility did not ensure the resident's credit card was free from misappropriation by a Certified Nurse Aide (CNA #1) who used the credit card without permission to purchase goods not intended for the resident from September 2022 through November 2022. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the recertification and abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #188) of 14 residents reviewed. Specifically, the facility did not ensure that staff did not make unauthorized purchases on Resident #188's credit cards and did not take appropriate action to resolve the misappropriation of Resident #188's personal property. This is evidenced by: A Policy and Procedure (P&P) titled Abuse Prohibition Program dated March 2021 documented the following: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made for 1 (Resident # 188) of 4 residents reviewed for abuse. Specifically, the facility did not ensure Resident #188's allegation made on 11/30/2022 that Certified Nurse Aides (CNAs) #1 and #2 were involved in the unauthorized use of their credit card was reported in a timely manner to the New York State Department of Health (NYSDOH). This is evidenced by: Resident #188 Resident #188 was admitted to the facility with diagnoses of congestive heart failure (CHF), major depression, and morbid obesity. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey from [DATE] to [DATE], the facility did not ensure residents received respiratory care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #31) of 6 residents reviewed for respiratory care. Specifically, the facility did not ensure Resident #31 had a physician's order for the use of continuous oxygen therapy recieved via nasal cannula and did not ensure the comprehensive care plan (CCP) included interventions related to the use of oxygen between [DATE] - [DATE]. This is evidenced by: Resident #31: Resident #31 was admitted to the facility with diagnoses of obstructive sleep apnea, COVID-19, and generalized anxiety disorder. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, the facility did not ensure prompt efforts were made to resolve a grievance for 4 (Resident #'s 56, 143, 170, and #446) of 4 residents reviewed for grievances. Specifically, for Resident #'s 56, 143, 170, and #446, the facility did not ensure there was documented evidence that the resident's complaints that Resident #596 had entered their rooms during the night, startled them from their sleep, and was observed going through their personal belongings and for Resident #56, had left the room with resident #56's personal belongings, was acknowledged by the facility and that the facility was actively working toward providing resolution to their complaints. This is evidenced by the following: The Policy & Procedure titled Concern and Comment Guidelines dated 12/2016 documented; [...]

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP's), that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs, for 6 (Residents #48, 53, 57, 102, 156, and 183) of 35 residents reviewed. Specifically: for Residents #48 and 57, the facility did not ensure a care plan was developed to address the resident's needs related to the use of psychoactive medications; for Resident #53, the facility did not ensure a care plan was in place to address that the resident was performing catheter care; for Resident #102, the facility did not ensure measurable objectives and interventions were included in the care plan that addressed the resident's hoarding of perishable food items; [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure that before it transferred a resident to a hospital or the resident goes on therapeutic leave, the nursing facility provided written information to the resident or resident representative that specified the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility, for 1 (Residents #175) of 2 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence that the resident and the resident's representatives were notified in writing of the bed hold policy when the residents were admitted to the hospital. This is evidenced by the following: Resident #175: [...]

Inspectors wroteBased on observation, interviews, and record reviews during a recertification survey, the facility did not ensure the assessment accurately reflected the resident's status for five (Resident #'s 22, 27, 52, 102, and #183) of thirty-five residents reviewed for accuracy of resident assessments. Specifically, for Resident #'s 22, 27 and #52, the facility did not ensure the Minimum Data Set (MDS) accurately reflected the residents' status related to the use of anticoagulant medication; for Resident #102, the facility did not ensure the MDS accurately reflected the resident's status related to locomotion on the unit; for Resident #183, the facility did not ensure the MDS accurately reflected the resident's status related to the use of antibiotics and a diagnosis of a urinary tract infection (UTI). This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, were provided by qualified persons in accordance with each resident's written plan of care, for one (Resident #163) of 2 residents reviewed for oxygen use. Specifically, the facility did not ensure that the liter flow of oxygen was set by staff who were qualified to do so. This is evidenced by: Resident #163: The resident was admitted to the nursing home on 3/28/19 with the diagnoses of respiratory failure and oxygen dependent, anemia, and malnutrition. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #81) of one resident reviewed for dialysis. Specifically, for Resident #81, the facility did not ensure the resident received ongoing assessments of their condition and monitoring for complications after dialysis treatments received at a certified dialysis facility and did not ensure that comprehensive care plans developed to address dialysis, were person-centered and met the individual needs of the resident. This is evidenced by: Resident #81: [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure that residents were free from unnecessary psychotropic medications for one (Resident #53) of five residents reviewed for psychotropic medications. Specifically, the facility did not ensure that the psychiatrist's recommended psychotropic medication reduction was implemented. This is evidenced by: Resident #53: The resident was admitted to the nursing home on 6/27/07, with diagnoses of major depressive disorder, diabetes, and hypertension. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A physician (MD) order dated 2/22/19, documented the resident was to receive Loxapine (antipsychotic medication) 5 mg; give 2 tablets one time a day at 8:00 PM. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the facility stored, prepared, and distributed food in accordance with professional standards for food service safety. Specifically, the facility did not ensure equipment was clean and the chemical solution in the three compartment sink was maintained at the correct concentration. This is evidenced by: Finding #1 During an observation on 4/23/19 at 8:27 AM, the stove and side of the ovens were soiled with grease and debris. During an interview on 4/23/19 at 8:27 AM, the Food Service Director (FSD) stated the cooks were responsible for cleaning the stove and ovens, and the equipment should have been cleaned. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his/her own and the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced by: A Policy and Procedure (P&P) titled Food Distribution to Residents documented for safety and sanitation purposes that families were encouraged to bring food that can be consumed in one setting and did not require storage. [...]