Shawnee Gardens Healthcare & Rehab Center

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (May 4, 2026)

EProtect each resident from the wrongful use of the resident's belongings or money.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0602 · Complaint inspection · Past Non-Compliance (Aug 20, 2025)

DEnsure each resident must receive and the facility must provide necessary behavioral health care and services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0740 · Complaint inspection · Deficient, Provider has date of correction (Mar 18, 2025)

FConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Potential for more than minimal harm · Administration Deficiencies · Tag F0838 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

FDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Potential for more than minimal harm · Administration Deficiencies · Tag F0941 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

FEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0942 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

FInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0945 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

EHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

EEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0806 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0676 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0744 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Complaint inspection · Deficient, Provider has date of correction (Oct 21, 2024)

FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Mar 23, 2023)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Mar 23, 2023)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Mar 23, 2023)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Deficient, Provider has date of correction (Mar 23, 2023)

DGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0582 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (Mar 23, 2023)

DNotify 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide 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.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0688 · Deficient, Provider has date of correction (Mar 23, 2023)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Mar 23, 2023)

DEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0726 · Deficient, Provider has date of correction (Mar 23, 2023)

DProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0744 · Deficient, Provider has date of correction (Mar 23, 2023)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Mar 23, 2023)