Shanoan Springs Nursing and Rehabilitation

Inspectors wroteOn 03/24/26, a past noncompliance Immediate Jeopardy (IJ) situation was determined to have existed related to the facility's failure to ensure Res #3 received a mechanically soft diet without bread per physician order. Res #3 was provided a grilled cheese sandwich and side salad for an evening meal, which resulted in a choking episode requiring emergency services. On 03/24/26 at 3:15 p.m., the OSDH was notified and verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents received physician ordered therapeutic diets. On 03/24/26 at 3:28 p.m., the administrator was notified of the immediate jeopardy situation. Based on observation, record review, and interview, the facility failed to ensure a resident received a physician ordered mechanical soft diet without bread for 1 (#3) of 3 sampled residents reviewed for therapeutic diets. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure advanced directives were sent with a resident during a transfer for 1 (#205) of 1 sampled residents reviewed for appropriate documentation sent to receiving provider. The administrator identified 49 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper personal protective equipment was used for 1 (#42) of 4 sampled residents reviewed for enhanced barrier precautions. The administrator identified 19 residents resided in the facility required enhanced barrier precautions.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. The facility identified 48 residents who received their meals from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were offered to formulate an advance directive, or implemented the choice to formulate an advanced directive, for three (#8, 20, and #42) and posted the correct information regarding code status for one (#2) for 24 residents reviewed for advance directives. The administrator identified 50 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at an appetizing temperature. The facility identified 48 residents who received their meals from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. wound care was provided in a sanitary manner for one (#20) of four residents observed for wound care, b. residents' catheters were not dragging on the floor for two (#8 and #26) of four sampled resident who had catheters, and c. a water management program was implemented to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings water system. The facility identified a census of 50 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was reported within two hours of the reported incident for one (#8) of three residents sampled for abuse. The administrator identified 50 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were accurate for two (#8 and #20) of 13 sampled residents whose resident assessments were reviewed. The administrator identified 50 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#2) of one sampled residents reviewed for PASRR.

Inspectors wroteBased on record review and interview, the facility failed to ensure nutritional supplements were given to one (#49) of two residents reviewed for weight loss. The DON identified 50 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow physician's orders for oxygen tubing care maintenance for one (#33) of one resident sampled for oxygen therapy. The administrator reported 50 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the use of side rails was appropriate for one (#49) of one sampled residents who were reviewed for side rails. The administrator identified 21 residents residing in the facility utilized bed rails of any type. Resident #49 was admitted with diagnoses including diffuse traumatic brain injury and hemorrhage with loss of consciousness of unspecified duration and need for assistance with personal care. An admission assessment, dated 03/25/24, documented the resident was severely impaired with cognition and was totally dependent with ADLs. A physician order, dated 03/25/24 at 7:00 a.m., documented to monitor placement and function of low air loss mattress every shift for placement and function. [...]

Inspectors wroteBased on record review and interview, the facility failed to: a. ensure a consultant pharmacist reviewed the medication of each resident in the facility monthly for two (#8 and #42) of five sampled residents reviewed for unnecessary medications. b. ensure the physician responded in the time frame documented by the facility policy to the MRR for one (#42) of five sampled residents reviewed for unnecessary medications, and c. ensure the physician responded to the MRR request for two (#8 and #42 of five sampled residents reviewed for unnecessary medications. The administrator identified 50 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure menus were followed. The facility identified one resident who received a puree meal, one resident who received finger foods, for a total of 48 residents who received their meals from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage from the kitchen was disposed of properly. The facility identified 48 residents who received services from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from abuse and neglect for two (#35 and #40) of three residents sampled for abuse. a. On 10/19/23, an initial Incident Report documented CNA #1 did place their hand over the mouth and nose of the Res #35 on 3 different occasions during a shower. It was also reported that CNA #1 told the resident to shut up. All those involved were suspended until the investigation was complete. CNA #1 was separated from employment immediately and CNA #2 was educated one-on-one related to reporting abuse immediately. On 10/24/23 an in-service and training was initiated by management to all staff members at the facility on abuse, neglect, dementia, reporting abuse, rights of residents, and bathing residents. On 10/26/23 management completed the in-service and training for all staff members at the facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the services to maintain grooming and personal hygiene. The Long-Term Care Facility Application for Medicare and Medicaid form documented 50 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the laundry room was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 56 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was kept clean, maintained in good repair, and chemicals were properly labeled. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 56 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to don gloves prior to the administration of subcutaneous insulin injections. The Resident Census and Conditions of Resident report documented 10 residents received injections in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure resident care plans were reviewed and revised after falls for two (#32 and #39) of two residents reviewed for falls. The Resident Census and Conditions of Resident report documented 56 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The Resident Census and Conditions of Residents form documented 56 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to limit PRN orders for psychoactive medications to 14 days for one (#12) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 14 residents received antianxiety medications.