Hannah B G Shaw Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) to prevent cross contamination. Findings include:Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to:3-302 Preventing food and ingredient contamination; (A) FOOD shall be protected from cross contamination by: (3) Cleaning equipment and utensils as specified under 4-602.11(A) and sanitizing as specified under S 4-703.11; 4-602.11 Equipment Food-Contact Surfaces and Utensils; (A) Equipment food-contact surfaces and utensils shall be cleaned: (3) Between uses with raw fruits and vegetables and with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD; (5) At any time during the operation when contamination may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed for one Resident (#2), out of a total sample of 15 residents, to ensure the Resident was free from physical restraints. Specifically, Resident #2's wheelchair was replaced with a Broda positioning wheelchair which no longer allowed the Resident to self-propel about the unit.Findings include:Review of the facility's policy titled Use of Restraints, revised April 2017, indicated, but was not limited to, the following:-Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.-Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.-When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented.-Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, for one Resident (#2), out of a total sample of 15 residents, the facility failed to develop a plan of care accounting for the Resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. Findings include: Resident #2 was admitted to the facility in June 2023 with diagnoses which included anxiety, depression, Alzheimer's disease, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD).Review of the Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident #2 was unable to complete the Brief Interview for Mental Status (BIMS) and had a diagnosis of PTSD. Further review of the MDS assessment indicated the Resident exhibited physical behavioral symptoms, verbal behavioral symptom, other behavioral symptoms, rejection of care, and wandering.Review of the Social Service admission Assessment, dated 7/5/23, indicated but was not limited to the following:-Resident #2 was in the process of divorcing his/her spouse-Resident #2 had some difficulty adjusting in his/her new environment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#26) from a total sample of 15 residents. Specifically, the facility failed to ensure respiratory equipment including oxygen tubing and bilevel positive airway pressure (bipap-medical device used to treat breathing disorders) equipment was properly maintained and stored in a clean and sanitary manner to decrease the risk of potential contamination and infection.Findings include:Review of the facility's policy titled Equipment Changing, undated, indicated but was not limited to the following:- All respiratory therapy equipment must be changed in order to prevent nosocomial infections (infections acquired in healthcare settings).-The equipment should be marked with the date that it was changed.-All equipment should be changed on a weekly basis as well as needed (PRN) if it becomes soiled or falls on the ground. This equipment includes but is not limited to: -air entrainment masks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and other opportunistic waterborne pathogens. Findings include: Review of the facility's policy titled Legionella Water Management Program, dated as revised September 2022, indicated but was not limited to: -As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease -The water management program includes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents residing on one Unit (Memory Care), out of six units in the facility. Specifically, the facility failed to ensure staff implemented facility sponsored group activities for all residents on the Memory Care unit designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Findings include: Review of the facility's policies titled Activity Programs, last revised June 2018, Therapeutic Programs and Activities for the Dementia Special Care Unit (DSCU), undated, and Individual Activities and Room Visit Program, last revised June 2018, indicated, but was not limited to: -The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. -Meaningful Activities: Design activities that engage residents mentally, physically, and emotionally,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit (Memory Care Unit) of six units in the facility. Specifically, the facility failed to ensure a three-tiered cart with hazardous items stored on it was not easily accessible to wandering residents on a Dementia Special Care Unit. Findings include: On 9/9/24 from 9:20 A.M. to 10:27 A.M. on the Dementia Special Care Unit, the surveyor observed two residents ambulate independently on the short hallway on the unit. On 9/9/24 at 10:27 A.M., on a short hallway on the unit, the surveyor observed a wheeled three-tiered cart with supplies on it. The top tier had stacks of folded towels on it covered with a folded bed sheet. The middle tier had incontinence briefs and slipper socks, and the bottom tier had a clear plastic bin that contained the following items: -8 (4 ounce) bottles of Medline Remedy Essentials Moisture Body Lotion -4 (1.5 ounce) bottles of FreshScent Roll-on Antiperspirant Deodorant -2 (4 ounce) bottles of FreshMoment Mouthwash -1 (8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure sufficient staffing levels were maintained to safely and adequately meet each resident's needs on all shifts every day on one (Memory Care) of three units in the facility. Findings include: Review of the Facility Assessment, dated reviewed 7/16/24, indicated the Facility was licensed for 67 beds and there were 12 beds on the Memory Care unit. -The average daily census of the Memory Care unit is 12. Further review indicated that the number of Certified Nurse's Aides (CNA) required to care for residents in the facility is: -2:10 (two staff to care for 10 residents) ratio Days (total licensed or certified) -2:10 ratio Evenings (total licensed or certified) -1.5:10 ratio Nights (total licensed or certified) -2:15 ratio Nights (short term rehab) (total licensed or certified) Review of the CNA daily assignment sheets and daily staffing schedules indicated that on 9/9/24, 9/10/24, 9/11/24, and 9/12/24 one CNA was assigned to the Memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed for three Residents (#57, #270, and #6), of 17 sampled residents, to ensure safe storage of medications and biologicals according to current standards of practice. Findings include: Review of the facility's policy titled Self-Administration of Medications, last revised February 2021, indicated but not limited to: -Self-administrated medications are stored in a safe and secure place not accessible by other residents. A. On 9/9/24 at 8:54 A.M., 10:57 A.M., and 1:36 P.M., the surveyor observed an inhaler containing Albuterol Inhalation Aerosol Solution (a bronchodilator used to relax airway muscles) on Resident #57's bedside table. Review of Resident #57's September 2024 Physician's Orders indicated but was not limited to the following: - May self-administer (dated 6/9/24) During an interview on 9/11/24 at 4:00 P.M., the Director of Nursing (DON) said Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was properly stored, labeled, and dated in the main kitchen; and 2. Ensure food was properly stored, labeled, and dated in five of five kitchenettes. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated, but was not limited to: - 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A)Except when PACKAGING FOOD using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and review of grievance documentation, the facility failed to formulate written grievances, follow up, and provide resolution for two Resident's Representatives who voiced grievances. Specifically, 1. Resident #48's Representative voiced concerns to the Administrator regarding resident safety due to low staffing on the Memory Care Unit and the frequent non-functioning of a doorbell outside the unit that alerts staff to unlock the door when someone wishes to gain access to the unit to see their loved one; and 2. Resident #45's Representative voiced concerns to the Administrator regarding resident safety due to low staffing on the Memory Care Unit. Findings include: Review of the facility's policies titled Grievances/Complaints, Filing and Grievances/Complaints, Recording and Investigating, last revised April 2017, indicated but was not limited to: -Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#43), out of a total sample of 17 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address the Resident's behavior of eating non-food items. Findings include: Review of the facility's policies titled Care Plans, Comprehensive Person-Centered and Care Planning-Interdisciplinary Team, last revised March 2022, indicated but was not limited to: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The IDT includes, but is not limited to the resident's attending physician. -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, record review, and policy review, the facility failed to implement interventions timely after significant weight loss was identified for one Resident (#20), out of a total sample of 17 residents. Specifically, the facility failed to: -assess and evaluate the Resident's nutritional status, and -consider interventions to curb further weight loss, resulting in additional weight loss over a period of two weeks. Findings include: Review of the facility's policy titled Weighing and Measuring the Resident, dated as last revised March 2011, indicated but was not limited to the following: -Report significant weight loss to the nurse supervisor. -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss = [usual weight - actual weight] / [usual weight] x 100): a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews, for one Resident (#20), out of 17 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated. Specifically, the facility failed to ensure Resident #20 was seen by a physician within the first 90 days of admission. Findings include: Review of the facility's policy titled Physician Visits, last revised April 2013, indicated but was not limited to: - The Attending Physician will visit residents in a timely fashion, consistent with the applicable state and federal requirements, and dependent on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. - The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.