A list of the most recent deficiencies for Shawn Manor Nursing Home. 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? |
|---|---|---|---|---|
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2023-11-02 | 2023-12-15 | N |
| 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 | 2023-11-02 | 2023-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-12-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-09 | 2022-10-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-09 | 2022-10-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-09 | 2022-10-24 | 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 | 2022-09-09 | 2022-10-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-09 | 2022-10-24 | N |
| 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 | 2022-09-09 | 2022-10-24 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-09-09 | 2022-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-09 | 2022-10-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-09 | 2022-10-24 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-09 | 2022-10-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-09 | 2022-10-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-09 | 2022-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-09 | 2022-10-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-09 | 2022-10-24 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-09 | 2022-10-24 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-20 | 2022-10-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-10-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-20 | 2022-10-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-29 | 2021-06-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-29 | 2021-06-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-31 | 2019-12-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-10-31 | 2019-12-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-31 | 2019-12-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-31 | 2019-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-31 | 2019-12-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-31 | 2019-12-16 | 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 | 2019-10-31 | 2019-12-16 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-10-31 | 2019-12-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-31 | 2019-12-16 | 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 | 2019-10-31 | 2019-12-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-31 | 2019-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-31 | 2019-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-31 | 2019-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-31 | 2019-12-16 | N |
