Shandin Hills Behavior Therapy Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food safety when: 1. A turkey meat product wrapped in foil was in the freezer, uncovered in a tray.2. One open box of fish filet was in the freezer with the inner plastic bag not properly sealed.3. One open box of frozen chocolate chip cookie dough had the inner plastic bag left open.4. Heavy grease, carbonized food residue (burnt food that has hardened and turned black due to heat and was not cleaned from surfaces) and burnt buildup were observed on cooking surfaces, ovens, and drip trays.5. Visible grease accumulation was observed on interior and exterior oven surfaces.6. Dark buildup and debris were observed on the oven door pane and bottom tray.7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a secure environment for 78 of 78 residents when multiples keys that open the main locked gate and doors to the facility were left hanging on the outside gate. This failure had the potential to place 78 residents at risk from unauthorized individual entering the building and or the residents leaving the facility through the unlocked door. During an observation on February 18, 2026, at 7:27 AM, surveyor found multiple keys that opened locked behavior doors and units hanging on the outside of the main entrance gate. There were no staff at the gate. Once the surveyors entered the building through the main entrance door, they proceeded through a second door, which leads directly to the resident's dining room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure proper disposal of garbage when the recycling dumpster located in the front area of the building was observed overflowing with cardboard and debris, preventing the lid from closing, with visible staining and debris on surrounding surfaces. This failure had the potential to attract vermin (pests or animals that spread diseases) in the facility that cares for 78 medically compromised residents. During a concurrent observation and interview on February 17, 2026, at 8:46 AM, with the Account Manager (AM 1), the recycling dumpster located in the front area of the building was inspected. The dumpster was overflowing with cardboard and debris, preventing the lid from fully closing. There was staining and buildup on the exterior surfaces, and debris was present on the surrounding ground area. [...]

Inspectors wroteBased on observation, interview, and measurement, the facility failed to ensure resident bedrooms provide a minimum of 80 square feet (the amount of space in the room) per resident in multiple resident rooms for 13 of 13 resident rooms reviewed (Rooms 30 through 42) located in Unit 2, affecting 29 of 29 residents residing in these rooms. This failure had the potential to limit residents' freedom of movement, increase the risk of accidents, interfere with safe mobility within the environment, and negatively impact on residents' health, safety, and quality of life. During an observation and measurement conducted on February 18, 2026, at 9:34 AM, in the presence of Maintenance Director (MDIR), resident rooms located in Unit 2 were measured using a tape measure to determine total livable floor space. Measurements were taken in inches and converted to square feet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent one of four sample residents (Resident 1) from being abuse by another Resident (Resident 2), when Resident 2 struck Resident 1 while he was in line with many other residents for medication. This failure resulted in Resident 1 suffered a scratch below the left eyebrow, a bruise on the left forehead, and a scratch on the left arm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement adequate monitoring and supervision for one of one resident (Resident 1) who had a history of elopement (leaving a designated area without permission), when the facility ' s back door was unlocked and Resident 1 left the facility without staff awareness on January 6, 2025, for 15 hours, before police brought Resident 1 back to the facility at midnight, on January 7, 2025. This failure placed Resident 1 at high risk for accidents and had the potential to place Resident 1's health and safety at risk and for him to experience some serious adverse outcome, due to exposure of the (outdoor) elements, as well as effects of his admitted use of marijuana ( a drug than can be smoke, vaporized or consume in milk) and alcohol while he was gone interacting with his prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their daily approved menu for lunch when, on November 12, 2024, Dietary [NAME] served a mixture of lettuce, tomato, and cheese together to serve with tacos and used a #24 scoop (1.33 ounces or 2-2/3 tablespoons), instead of ¼ cup (4 tablespoons) shredded lettuce and diced tomato topping and 1 tablespoon of shredded cheddar cheese. This failure had the potential for residents to compromise their nutritional status when menus are not followed for 78 of 78 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents rights to forms of communication were respected for three of six residents (Residents 24, 31 and 66) when Residents 24, 31 and 66 did not receive mail on Saturdays. This failure resulted in Residents 24, 31 and 66's not having means of communication with individuals inside or outside the facility, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for dysphagia mechanical soft diet (texture-modified diet that restricts foods that are difficult to chew or swallow) when one of twenty two sampled resident (Resident 16) did not receive her physician ordered therapeutic diet (a meal plan that's prescribed by a doctor and created by a dietician to treat a medical condition) on the following days: Received regular tortilla and regular green chili rice instead of pureed tortilla and pureed green chili rice for lunch on November 12, 2024. Received a whole piece of bread and chopped roast pork instead of pureed bread and ground roast pork for lunch on November 13, 2024. This failure had the potential for Resident 16 that received this diet to be at risk for choking and impact the resident's nutritional needs and health outcomes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure when one of one sampled residents (Resident 278) food preferences were not honored when Resident 278 asked for ketchup for his lunch on November 12, 2024 and staff said no. This failure had the potential to result in unmet care of needs for Resident 278 which could potentially affect the residents nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. There was two plastic drawers with food crumbs and spill stains inside the drawers. The plastic drawer base and the shelf that the drawers were sitting also had a build-up of food crumbs. 2. There was a black build-up on floor under the three compartment sinks. Looks like black sludge with food. The had the potential for microorganism growth and to attract pests. 3. The meat slicer had old meat crusted on the blade. This had potential to contaminate meat sliced on the slicer. 4. The steam table in unit one dining room was dirty, had grease and grime on the front of the unit and the shelf under the steam table had a buildup and food crumbs. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for 13 rooms (Rooms 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42). This failure had the potential to limit freedom of movement and affect the health and safety of 29 residents who reside in these rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. There were eight outdated cups of prune juice found in the kitchen refrigerator, and one box of outdated saltine crackers was found in the dry food storage and were available for use. 2. There were food crumbs and trash under the stove. These failures had the potential to expose 77 highly susceptible residents who received food from the kitchen to foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the water management plan in accordance with their own policy and procedure. This failure had the potential to result in causing water borne illness(illness caused by ingestion of contaminated water) to 77 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure informed consents (process in which a health care provider educates a patient about the risk and benefits and alternatives) were obtained for a resident (Resident 54) reviewed for use of psychotropic medication (a drug which affects behavior, mood thoughts, or perception). This failure had the potential for Resident 54 and his representative to not be informed of Resident 54's current health condition and treatment options, which could negatively impact Resident 54's health and safety.

Inspectors wroteBased on observation and interview, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for 13 rooms (Rooms 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42). This failure had the potential to limit freedom of movement and affect the health and safety of 29 residents who reside in these rooms.