Rehab At Shannondell

Based on review of clinical records and interview with staff, it was determined that the facility failed to report an elopement incident to the department of health for one of twelve residents reviewed (Resident R125)Review facility policy on Patient Elopement dated September 2022 revealed that under section Purpose: This policy ensures that patients that leave the facility without staff knowledge or without adequate supervision / safety is managed appropriately. Under section Procedures #3 Patient's Rights with Outings: patients who are not at risk of elopement will have their rights preserved and are free to move throughout the facility and leave the facility with supervision.Review of Resident R125's clinical record revealed that Resident R125 was admitted to facility on March 16, 2026, with diagnoses of but not limited to Intertrochanteric Fracture of the Right Femur, Presence of Right Artificial Hip Joint.Review of the MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated March 26, 2026, revealed section C0500. BIMS (brief…

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 review of clinical records and interview with staff, it was determined that the facility failed to conduct a timely and thorough investigation of an elopement incident for one of twelve residents reviewed (Resident R125).Review facility policy on Patient Elopement dated September 2022 revealed that under section Purpose: This policy ensures that patients that leave the facility without staff knowledge or without adequate supervision / safety is managed appropriately. Under section Procedures #3 Patient's Rights with Outings: patients who are not at risk of elopement will have their rights preserved and are free to move throughout the facility and leave the facility with supervision.Review of Resident R125's clinical record revealed that Resident R125 was admitted to facility on March 16, 2026, with diagnoses of but not limited to Intertrochanteric Fracture of the Right Femur, Presence of Right Artificial Hip Joint.Review of the MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated March 26, 2026, revealed section C0500. BIMS…

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 review of clinical records and interview with staff, it was determined that the facility failed to ensure that residents are supervised which resulted in a resident leaving the facility without the knowledge of the staff for one on twelve residents reviewed (Resident R125).Review facility policy on Patient Elopement dated September 2022 revealed that under section Purpose: This policy ensures that patients that leave the facility without staff knowledge or without adequate supervision / safety is managed appropriately. Under section Procedures #3 Patient's Rights with Outings: patients who are not at risk of elopement will have their rights preserved and are free to move throughout the facility and leave the facility with supervision.Review of Resident R125's clinical record revealed that Resident R125 was admitted to facility on March 16, 2026, with diagnoses of but not limited to Intertrochanteric Fracture of the Right Femur, Presence of Right Artificial Hip Joint.Review of the MDS (minimum data set, a federally required resident assessment completed at a specific…

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 review of facility policy, review of clinical record, observations, and interview with staff it was determined that the facility failed to administer intravenous (IV) medications in accordance with professional standards of practice for one of twelve residents reviewed (Resident R8). Findings include:Review of facility policy Central Venous Catheter Dressing Change (allows delivery of medications directly into the blood stream) dated May 2011, revealed the Registered Nurse will measure external portion of catheter (ensures that the catheter is properly positioned within the vein) and document in residents electronic medical record and further ensure external measurement is what is documented on the IV insertion records and notify physician of any discrepancies.Review of Resident R8's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 15, 2026, revealed the resident was admitted to the facility on [DATE], and had diagnoses of wound infection 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 review of facility policy, review of clinical documents, observation, and interviews with staff, it has was determined that the facility did not ensure that oxygen therapy was provided in accordance with professional standards of practice related to physician orders and documentation for two out of ten residents reviewed (R1, R12) Findings include:Review of facility policy titled Oxygen Utilization/Storage, last updated July 2021, revealed that Oxygen is prescribed by the physician and must include .device (e.g., nasal cannula, simple mask), flow rate .duration (continuous, exertion, sleep, PRN with clear parameters).Review of clinical records for resident R1 revealed that he was admitted on [DATE], with diagnoses including, but not limited to, acute and chronic respiratory failure, pneumonia, congestive heart failure (CHF, a condition where the heart is too weak or stiff to pump blood effectively, causing fluid buildup in the lungs or body. This can cause shortness of breath, fatigue, and swelling),…

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 clinical record, hospital record and policy and procedure review and interviews with staff, it was determined that the facility failed to immediately inform the physician of an accident that resulted in injury for one of five residents reviewed. (Resident R1)Findings include:A review of the policy titled physician notification dated November, 2019 revealed that it was the responsibility of the facility to notify the resident's attending physician of changes in the resident's medical condition or status. The policy indicated that the charge nurse was responsible to notify the resident's attending physician when there had been an accident or incident involving the resident. The nurse was also responsible for documenting the details and observations pertinent for the physician notification. The nurse was responsible for recording any instructions given to the nurse by the physician related to the incident or accident. Clinical record review revealed that Resident R1 had fallen at 5:00 a.m., on April 28, 2025. The nursing note at 7: 39 a.m., on April 28, 2025 indicated that 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 review of clinical record, review of policy and procedures, interviews with staff, and review of hospital records, it was determined that the nursing staff failed to properly supervise one of five residents reviewed during transfer and ambulation. (Resident R1) Findings include:A review of the facility policy titled fall management dated February, 2023 revealed that it was the responsibility of the facility staff to assess residents who were at risk for falls and identify the reason for the fall to prepare a care plan to reduce the potential for future falls. This policy indicated that a plan of care would be developed and initiated to address fall risk factors and measures to prevent falls. A facility incident report will be completed post fall and witness statements/information would be documented and used to develop care plan approaches to prevent falls.A review of the facility's policy titled incident and accident investigation dated January, 2022 revealed that the purpose of the investigation of an…

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, review of faciltiy policy and review of clinical records, it was determined that the facility failed to inform the resident and/or her responsible party of their right to formulate an advanced directive upon admission, and failed to clarify the resident's code status upon admission to ensure that the resident's wishes regarding end of life care would be honored for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Patient Code Status, with a revision date of [DATE], indicted that the purpose of the policy was to ensure that patients are able to choose their code status and to ensure that all necessary documentation is included in patient's chart. The policy also indicated that social services will verify the patient's code status choice (DNR or Full Code) with their admission assessment within 1 business day of a resident's admission. Continued review of the policy indicated that a physician's order for DNR will be contained in the electronic…

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, review of clinical records and staff interview, it was determined that the facility failed to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable an accurate reconciliation and accountability for two of three medication carts observed. (Medication Cart 3rd Floor B Front and Medication cart 3rd Floor B Back) Findings: Review of facility narcotic book for Medication Cart 3rd Floor B Front conducted on July 10, 2024, at 8:52 p.m., during medication administration observation with licensed nurse, Employee E5 revealed an entry for July 10, 2024, with time written 1900 (7:00 p.m.). Further, the column for Nurse going off duty for July 10, 2024, with time written for 1900 had a signature. Interview with licensed nurseEmployee E5 conducted at the time of the observation, revealed that licensed nurses work a 12-hour shift and that between shifts, the outgoing and incoming nurses count the narcotics together and that the once they are done counting the controlled substances in the cart, the outgoing nurse signs 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 observation, interviews with staff, review of clinical records and facility policy, it was determined that the facility failed to have a medication error rate less than five percent (Residents R9 and R244). Findings include: Review of the facility's medication policy dated 2/2017 states, All medications are administered safely and appropriately to all residents and to follow 6 Rights of Medication Administration during medication pass (right resident, right medication, right dose, right route, right time, right documentation). The facility's medication error rate was 8 % based on 25 medication opportunities with two medication errors. Review of Resident R9's physician orders instructed to take Cyanocobalamin (Vitamin B-12) 1,000 mcg sublingual route (placed under your tongue to dissolve) once daily. Observation of a medication administration pass on July 11, 2024, at 9:08 a.m. with Registered Nurse, Employee E3 revealed the nurse administered Cyanocobalamin by mouth to Resident R9. Review of Resident R244's physician orders instructed to take Cyanocobalamin 1,000 mcg…

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 review of clinical records, reviewof facility policy, observation, and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards for one of three medication carts observed (Med cart 3rd B back) and one of two medication rooms observed (Third-floor medication room). Findings include: Review of facility policy for medication administration dated February 2017, revealed that under section Policy: all medications are administered safely and appropriately to all residents. Under section Process: Check medication for expiration date and discard if indicated and check multi dose vials for date when opened and discard if indicated. Observation of med cart 3rd B back conducted during medication administration on the 3rd floor unit on [DATE], at 9:12 a.m. with Licensed nurses, Employee E6 and Employee E8 revealed a Glucagon injection (an emergency medication used to treat severe hypoglycemia (low blood…

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.