Shearer-Richardson Memorial Nursing Home

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to ensure a resident had a safe and homelike environment as evidenced by a broken bathroom wall tile and a broken towel holder in the bathroom for one (1) of 67 residents' rooms observed. Resident #55Findings include: Review of the facility's policy titled, Safe and Homelike Environment dated 7/29/25, revealed, In accordance with residents' rights, the facility will provide a safe, clean comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) status change was completed when a resident's original diagnosis was corrected to reflect the presence of a mental illness for one (1) of four (4) residents reviewed for PASRR. Resident #25.

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to ensure that all nursing staff had valid and current certification to provide care to residents. This deficient practice resulted in a Certified Nursing Assistant (CNA) working 15 shifts while her certification was expired, which placed residents at risk of receiving care from an unqualified individual for one (1) of (44) CNA certifications reviewed. (CNA #1).

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to ensure laboratory tests were obtained as ordered by the physician for (1) one of five (5) resident laboratory reviews conducted. (Resident # 14).

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident had a functioning call light system in the bathroom for one (1) of 67 residents' rooms observed. Resident #55Findings include: Review of the facility's policy titled, . Call Lights: Accessibility and Timely Response dated [DATE], revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 7. The call system must be accessible to the residents at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 8. [...]

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from abuse including involuntary seclusion, verbal abuse and unreasonable confinement by staff members physically restraining a resident for one (1) of three (3) residents sampled. Resident #1.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to report an allegation of abuse and involuntary seclusion within the time frame required for one (1) of three (3) allegations of abuse reviewed.

Inspectors wroteBased on observation, staff and resident representative (RR) interview and facility policy review revealed the facility failed to ensure residents were treated with dignity and respect as evidence by staff members calling the residents by their last name only and failing to use a salutation for two (2) of 18 residents sampled during this survey. Resident #2 and Resident #39. Findings Include Record review of the facility policy review titled, Promoting/Maintaining Resident Dignity with a revision date of 10/2/23 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. [...]

Inspectors wroteBased on resident representative (RR) and staff interview, record review and facility policy review the facility failed to ensure a resident representative's grievance was resolved for one (1) of 18 residents reviewed, Resident #2. Findings Include Record review of the facility policy titled, Resident and Family Grievances with a revision date of 10/1/23 revealed under, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines .#12. The facility will make prompt efforts to resolve grievances. On 9/30/24 at 11:20 AM, during a phone interview with Resident #2's RR revealed he has complained numerous times to the Director of Nurses (DON) and Administrator regarding his mother. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) Assessment for one (1) of 21 residents reviewed for MDS assessments.

Inspectors wroteBased on observation, record review, staff and resident interviews and facility policy review, the facility failed to develop a care plan for Resident #10 related to chronic pain for one (1) of 18 residents reviewed.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to develop and implement a person-centered care plan for residents requiring assistance with Activities of Daily Living (ADL) (Residents #4, #6, #27, and #35), a resident requiring assistance with transfers using a lift (Resident #53), a resident with a diagnosis of Post-Traumatic Stress Disorder (Resident #47), and a resident requiring dental services and ADLs, (Resident #34) for seven (7) of 19 resident care plans reviewed.

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from accidents during a lift transfer by using the inappropriate lift for one (1) of 19 residents reviewed for investigations.

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review, the facility failed to prevent neglect by failing to provide goods and services to a resident to ensure that the resident received the necessary Activities of Daily Living (ADL) and oral care for one (1) of 17 residents sampled. Resident #34. Findings Include: Record review of the facility policy titled Abuse, Neglect and Exploitation undated revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Policy Explanation and Compliance Guidelines: . 2. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . 6. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to accurately complete the oral/dental section of the admission comprehensive assessment on a resident with dental concerns for one (1) of five (5) residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review the facility failed to remove facial hair, bathe, shave, and perform nail and oral care for residents requiring assistance with their Activities of Daily Living (ADL) for five (5) of 19 sampled residents reviewed for ADLs. Resident #4, Resident #6, Resident #27, Resident #34, and Resident #35 Findings Include: Record review of the facility policy titled Activities of Daily Living (ADLs) with a revision date of 3/10/23 revealed under, Policy: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Also revealed under, Policy Explanation and Compliance Guidelines: . 3. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review the facility failed to deliver care and services for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 66 residents reviewed. Resident #47.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to provide necessary dental services to meet a residents dental needs for one (1) of 19 residents reviewed. Resident #34 Findings Include: Record review of the facility policy titled Dental Services with a revision date of 3/14/23 revealed, Policy: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care Policy Explanation and Compliance Guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment processes and are addressed in each resident's plan pf care. a. Oral/dental status shall be documented according to assessment findings. c. Referrals to dietician, speech therapist, physician, or dental provider shall be made as appropriate . [...]