Shaker Gardens Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Shaker Gardens Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 16, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, interviews, local police report review, hospital record review, and facility policy review, the facility failed to provide adequate supervision to prevent a resident, with altered mental status and a history of wandering behaviors, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death when on 05/26/26 at approximately 9:35 P.M., Resident #48 left the facility without staff knowledge and was later found by the local police approximately five miles away. […]

• No harm, potential for more than minimal, widespreadF921May 1, 2026

  Based on observation, resident interview, and staff interview, the facility failed to ensure an adequate supply of washcloths and towels were available for resident care needs. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.Findings include:Observation and interview with Certified Nurse Aide (CNA) #299 on 05/01/26 at 8:28 A.M. revealed there were no washcloths or towels were available on the first floor for resident care needs.Observation on 05/01/26 at 8:48 A.M. outside the laundry room revealed 26 bags of dirty laundry and three bags of clean laundry pending delivery to residents. Interview with Maintenance Director (MD) #200 at that time revealed only one clothes washer was operational. […]

• No harm, potential for more than minimal, widespreadF814May 2, 2022

  Based on observation and staff interview, the facility failed to ensure the dumpsters and surrounding areas were maintained and free from trash and debris. This had the potential to affect all 42 residents currently residing in the facility. Finding include: Observation on 04/26/22 at 10:42 A.M. of the outside dumpsters revealed two dumpsters, both with the lids open with a moderate to a large amount of debris and trash on ground around the dumpsters. Interview on 04/26/22 at 10:42 A.M. with Dietary Manager (DM) #536 verified the observation.

• No harm, potential for more than minimal, widespreadF880May 2, 2022

  Based on observations, staff interview, record review, review of facility infection control policies and the Centers for Disease Control and Prevention (CDC) website the facility failed to implement infection control procedures for Personal Protective Equipment (PPE). This had the potential to affect all 42 residents currently residing in the facility. The facility also failed to ensure [CONDITION(S)] (TB) testing was completed as required. This affected two (Residents #30 and #38) of five residents reviewed for TB testing. Findings include: 1. Observation on 04/25/22 at 7:13 P.M. revealed on the third floor, Licensed Practical Nurse (LPN) #631 with her facemask pulled down exposing her mouth and nose. LPN #631 was standing at the medication cart that was in front of the nurses' station. […]

• No harm, potential for more than minimal, widespreadF804Jan 11, 2022

  Based on interview, observation and review of temperature logs the facility failed to ensure foods were served at a palatable and appetizing temperature. This affected 39 of 41 residents who take food by mouth. Findings include: Interviews with Residents #3, #18 and #35 on 01/10/22 between 8:35 A.M. and 8:50 A.M. revealed taste and temperature of the food was not palatable. The residents reported sometimes the staff just microwave it before serving the food. On 01/10/22 at 8:19 A.M. tray line was observed for the breakfast meal. All meals were served in three compartment, clear plastic containers with attached lids. Interview with Cook #230 on 01/10/22 at 8:25 A.M. indicated the facility was using disposable items due to having COVID 19 positive residents in the building. […]