Shawn Manor Nursing Home

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurately coded for two (#3 and #5) of 13 sampled residents whose assessments were reviewed. The DON identified four residents who were ordered antiplatelet medications and five residents who were ordered anticoagulant medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure the food service supervisor completed certification as a certified dietary manager within three years of beginning employment per State requirement. The administrator identified 26 residents resided in the facility and 23 residents received services from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to adhere to enhanced barrier precautions for: a. one (#9) of one sampled resident reviewed for a urinary catheter; and b. one (#14) of one sampled resident observed for medication administration via peg tube. The administrator identified 26 residents resided in the facility and 11 residents were on enhanced barrier precautions.

Inspectors wroteBased on record review and interview, the facility failed ensure the co-pay charged to a resident account did not exceed the Medicaid payment limit for one (Resident #5) of four resident whose monies were held in the resident trust. The Administrator identified 20 residents who received Medicaid and 17 residents whose monies were held in the facility trust.

Inspectors wroteBased on observation, record review, and interview, the facility failed to perform range of motion and positioning for one (#12) of one resident whose clinical records were reviewed for range of motion and positioning. The DON identified two residents with orders for range of motion and positioning.

Inspectors wroteBased on record review and interview, the facility failed to create a water management plan for the prevention of waterborne pathogens for the facility. The Administrator stated 29 residents resided at the facility.

Inspectors wrote4. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of conciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [...]

Inspectors wrote6. Resident #32 had diagnoses which included, dementia, mood disturbance and anxiety. A five day assessment, dated [DATE], read in parts, ~ had severe cognitive impact; ~ inattentive behavior with fluctuations; ~ disorganized thinking, present with fluctuations; and ~ altered level of consciousness, present with fluctuations. A Nurse's Note dated, [DATE] at 9:00 a.m., read in part, .Late Entry: Note Text: DELAYED ENTRY: [Resident #32] was found visiting .[Resident #85] in [Resident #85's] room with the door shut. Informed by nurse it is fine to visit, but the door has to remain open. [Resident #32] shortly returned to .own room where .[Resident #85] followed and closed the door again. When nurse returned to room and opened door .[Resident #85] hands were groping at [Resident #32's ] lap asking why not and [Resident #32] was heard stating no because my pants are too tight. [...]

Inspectors wroteBased on record review and interview the facility failed to report allegations of abuse and neglect to local law enforcement and OSDH for for four (#85, 25, 32, and #22) of six sampled residents reviewed for abuse. a. Three (#85, 25, and #32) of six sampled residents were identified to be involved with resident to resident sexual encounters, to include touching, petting, and groping. b. One resident (#22) was identified to have physical aggression toward other residents, to include hitting, scratching, and attempting to run into residents while propelling self in hallway. The Resident Census and Condition of Residents identified 34 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence that allegations of abuse were thoroughly investigated, implement interventions to protect residents from further abuse, and report abuse allegations within the appropriate time frame to OSDH, APS, and Local Law Enforcement. This affected four (#85, 22, 25, and #32) of six sampled residents reviewed for abuse. a. Three residents (#85, 25, and #32) of three sampled residents who were identified to be involved with resident to resident sexual encounters, to include touching, petting, and groping. b. One resident (#22) identified to have physical aggression toward other residents, to include hitting, scratching, and attempting to run into residents while propelling self in hallway. The Resident Census and Condition of Residents identified 34 residents resided in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were offered an opportunity to up-date an advanced directive for two (#1 and #27) of three sampled residents reviewed for advanced directives. The Resident Census and Condition of Residents documented 34 residents resided in the facility with four residents having formulated an advanced directive.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessment accurately reflected the residents status for two (#1 and #24) of 14 sampled residents. The Resident Census and Condition of Residents identified 34 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure monitoring was completed for the effectiveness of a hypnotic medication for one (#25) of one resident reviewed for the administration of a hypnotic medication. The Resident Census and Condition of Residents documented two residents had physician orders for a hypnotic medication to be administered, and the facility census was 34.

Inspectors wroteBased on record review and interview the facility failed to respond in a timely manner to a pharmacists recommendations for a GDR of a psychotropic medication for one (#16) of five sampled residents reviewed for pharmacy recommended GDR's. The Resident Census and Condition of Residents, documented 21 residents received psychotropic medications.

Inspectors wroteBased on observation and interview the facility failed to ensure a. staff wore an N-95 while assigned in the COVID-19 isolation unit; and, b. unvaccinated staff wore an N-95 while in the facility per facility policy. The DON reported 34 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to implement/use a SBAR tool for the use of antibiotics for one (#14) of five sampled residents reviewed for the use of antibiotics. The DON reported 34 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure consent forms were completed for: a. pneumococcal vaccines were offered to two (#20 and #22) of five sampled residents reviewed for pneumococcal vaccines; and b. influenza vaccines were offered for one (#20) of five sampled residents reviewed for influenza vaccines. The Resident Census and Condition of Residents, documented five residents had received pneumococcal vaccines, and 20 residents had received influenza vaccines. The Resident Census and Condition of Residents documented 34 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure unvaccinated staff tested daily per facility protocol for two (LPN #4 and CMA #1) of three unvaccinated staff reviewed for COVID-19 testing. The DON reported three staff who had COVID-19 vaccination exempt status. The Resident Census and Condition of Residents documented 34 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a base line care plan for one (#31) of one newly admitted residents reviewed for base line care plans. The DON reported 34 residents resided in the facility. The Resident Matrix for newly admitted residents, documented three new admissions in the past 30 days.

Inspectors wroteBased on record review and interview the facility failed to ensure the comprehensive care plan was updated for one (#24) of 14 sampled residents. The Resident Census and Condition of Residents documented 34 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to promptly notify the physician of STAT laboratory results for one (#18) of three sampled residents reviewed for lab results. The DON reported 34 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure LPN #3 completed training on abuse and neglect prior to being assigned duties with direct care. The Resident Census and Condition of Residents identified 34 residents resided in the facility.