Deficiency Records for Shawnee Gardens Healthcare and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Shawnee Gardens Healthcare and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-09-14 | 2023-10-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-15 | 2023-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-15 | 2023-06-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-15 | 2023-06-16 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-04-11 | 2023-05-24 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-02-15 | 2023-04-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-24 | 2023-03-23 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-24 | 2023-03-23 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-24 | 2023-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-24 | 2023-03-23 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-24 | 2023-03-23 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-24 | 2023-03-23 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-24 | 2023-03-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-24 | 2023-03-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-14 | 2023-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-03-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-14 | 2023-03-23 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-15 | 2023-02-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-25 | 2022-11-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-25 | 2022-11-18 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-25 | 2022-11-18 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-06-10 | 2021-07-13 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-10 | 2021-07-13 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-06-10 | 2021-07-13 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-06-10 | 2021-07-13 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-10 | 2021-07-13 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-10 | 2021-07-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-07-13 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-06-10 | 2021-07-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-29 | 2021-05-04 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-03-29 | 2021-05-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-29 | 2021-05-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-29 | 2021-05-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-29 | 2021-05-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-29 | 2021-05-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-17 | 2019-08-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-07-17 | 2019-08-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-17 | 2019-08-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-17 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-17 | 2019-08-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-17 | 2019-08-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-17 | 2019-08-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-17 | 2019-08-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-17 | 2019-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-17 | 2019-08-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-20 | 2019-04-11 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-20 | 2019-04-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-20 | 2019-04-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-20 | 2019-04-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-20 | 2019-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-20 | 2019-04-11 | N |
