The Shannon Gray Rehabilitation & Recovery Center

Based on observations and staff interviews, the facility failed to remove expired medications stored in 1 of 3 medication rooms and 1 of 6 medication carts reviewed for medication storage (Over the Counter (OTC) Medication Storage Room and Medication Cart for 800 hall).The findings included:a. An observation of the Over the Counter Medication Storage Room was conducted on 6/24/2026 at 9:33 AM in the presence of the Supply Coordinator. The observation revealed the following expired medications:-Two bottles of vitamin D-3 10 micrograms (mcg) film-coated tablets (a dietary supplement medication) with an expiration date of 9/2025. Both bottles were opened and observed without labels indicating their opening dates. One bottle contained 65 tablets, and the second bottle contained 34 tablets. The Supply Coordinator confirmed the expiration date by reading aloud the date printed on the bottles and confirmed the bottles were opened and undated.-One tube of triple antibiotic ointment, 0.5 ounce, with an expiration date of 10/2025. The Supply Coordinator confirmed the expiration date by…

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 record review, staff and resident interviews, the facility failed to provide a resident with dignity and respect when Nurse Aide (NA) #1 confronted Resident #77 about reporting her and making false accusations to management. Resident #77 stated this made her feel fearful and treated unfairly. The facility also failed to provide dignity and respect to Resident #35 when NA #2 spoke smack and not very nice to the resident. Resident #35 stated this made him feel frustrated. This occurred for 2 of 4 residents reviewed for dignity (Resident #77 and Resident #35). The findings included:Resident #77 was admitted to the facility on [DATE] with diagnoses of lumbar spina bifida without hydrocephalus (a birth defect where the bones in the lower back do not fully close leaving a gap without fluid on the brain). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact and required partial/moderate assistance with bathing and was dependent on toileting. There were no behaviors…

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, staff and Physician interviews, and record review, the facility failed to implement their infection control policy and procedure, when a Nurse Aide (NA) failed to perform hand hygiene after the completion of catheter care for Resident #36 who was on Enhanced Barrier Precautions (EBP) for an indwelling catheter. This deficiency occurred for 1 of 4 staff members reviewed for infection control practices (NA #4). The findings included:A review of the facility's policy and procedure titled Infection Control in Long Term Care (LTC) Policy dated April 2026 read in part:Use a piece of personal protective equipment one-time-then throw it away.Change gloves when they are soiled, and when moving from a contaminated to clean area of the body.A review of facility's Infection Prevention and Control Program (IPCP) dated April 2024 read in part: The hand hygiene procedures were to be followed by staff involved in direct resident contactReview of the Hand Hygiene Policy (no date), staff were required to execute hand hygiene when the following tasks are performed:After handling…

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 facility record review, hospital emergency department record review, and Resident, Responsible Party, staff, and Medical Director Interviews, the facility failed to ensure a resident received the medications ordered for her by the physician at discharge from the facility. At the time of discharge on [DATE] medications belonging to another resident were inadvertently provided to Resident #1. On 10/21/25 the Responsible Party looked at the medication packaging and realized the medications were prescribed for another resident and she was taken to the Emergency Department (ED) for evaluation. The ED Provider Note stated Resident #1 had no complaints, but the RP stated she was shaky over the last few days. The ED Provide Note further stated Resident #1 looked good clinically with normal laboratory results and the results of the electrocardiogram completed that day were at her baseline. No treatment or interventions were provided and the ED provider indicated he did not see any evidence of a major medication…

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 record review, and staff and Ombudsman interviews, the facility failed to notify the Ombudsman, the residents and/or the resident representatives in writing of a resident transfer for 2 of 3 residents reviewed for hospitalization (Resident #88 and Resident #81). The findings included: 1. Resident #88 was initially admitted to the facility on [DATE] and a reentry date of 1/29/25. The nursing progress note dated 1/28/2025 at 2:30 PM revealed Resident #88 was transferred to the hospital for evaluation. Resident #88 was discharged from the facility on 1/28/25 and returned to the facility on 1/29/25. A telephone interview was conducted on 4/2/25 at 1:07 PM with the Ombudsman who revealed she had not received written notification of hospital transfers since November of 2024. Multiple attempts were made to interview the responsbile party however attempts were not successful. An interview was conducted on 4/2/25 at 2:45 PM with the Administrator. He stated the facility has had administrative staff changes and…

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 staff interviews and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of active diagnoses and urinary catheter for 2 of 20 residents reviewed for MDS accuracy (Residents #39 and #100). The findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder. A record review indicated Resident #39 had an active diagnosis of Post-Traumatic Stress Disorder (PTSD) since 8/8/23. The annual Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #39 had an active diagnosis of PTSD in the Psychiatric/Mood Disorder section An interview was conducted on 4/3/25 at 10:25 AM with Minimum Data Set (MDS) Nurse #1. She stated it was an oversight that she did not code an active diagnosis of PTSD in the Psychiatric/Mood Disorder section of Resident #39's annual MDS assessment dated [DATE]. An interview was conducted on 03/06/25 at 10:50 AM with the Administrator. He stated she expected 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Wound Care Physician, and lab vendor interviews, the facility failed to notify the Wound Care Physician of a positive wound culture lab result when it was reported to the facility which delayed initiating antibiotics for 3 days. This deficient practice affected 1 of 2 sampled residents (Resident #53). Findings included: Resident #53 was admitted to the facility on [DATE] with the diagnosis of dementia. The annual Minimum Data Set, dated [DATE] for Resident #53 documented she had an intact cognition, a diagnosis of one stage 3 pressure ulcer, and the pressure ulcer stage 3 was reported not present on admission or reentry. The resident was frequently incontinent of bladder and always incontinent of bowel. The care plan dated 3/20/25 for Resident #53 had interventions for pressure reduction, nutrition supplementation for wound healing, and pressure ulcer wound care. The resident was at risk of developing pressure ulcers. Resident #53 had a Wound Care Physician progress note dated…

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, observation and interviews of the staff and wound care physician, the facility failed to follow their infection control policy for hand hygiene and glove use when the Wound Care Nurse did not perform hygiene and don new gloves after the dirty portion of the pressure ulcer dressing change and before beginning the clean portion of the dressing change (Resident #53). This deficient practice occurred for 1 of 2 staff observed for infection control practices. Findings included: The infection control policy last updated on 10/22/24 documented, in part, 1. Hand hygiene d. Wash hands after removing gloves. 2. Gloves e. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. On 04/02/25 at 10:35 am an observation of…

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, record review and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide (NA) #1 and NA #2 failed to remove their masks before exiting a COVID-19 isolation room for 2 of 7 residents reviewed for infection control. (Resident #10 and Resident #24) Findings included: Record review of the Facility Infection Prevention and Control Program Policy last revised 7/13/23 revealed the program outlines strategies designed to reduce the risk of transmission of infectious agents among healthcare workers, residents, and visitors. The policy further stated transmission-based precautions will be utilized in addition to Standard Precautions when the route of transmission is not completely interrupted using Standard Precautions along. The policy indicated that the three categories of transmission-based precautions were contact, droplet (including enhanced) and airborne and appropriate use of personal protective equipment was required. Review of isolation signage placed on the doorway of residents on droplet contact precautions…

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.