Shaker Place Rehabilitation and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 20, 2023

  Based on record review and interviews conducted during an abbreviated survey (Case #'s NY00283709 and NY00305004), the facility did not ensure each resident received adequate supervision to prevent accidents for 2 (Resident #'s 1 and #2) of 2 residents reviewed for accidents. Specifically, for Resident #1, who was non-ambulatory, was care planned as at risk for falls. Resident #1 had been restless, agitated, and was found attempting to transfer themselves. The facility did not ensure Resident #1 was provided with supervision to prevent falls on 9/19/2022. The resident was found lying on the floor in the lounge area with their face in a pool of blood. […]

• No harm, potential for more than minimal, widespreadF610Oct 10, 2023

  Based on observation, record review, and interviews during the recertification survey and an abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure alleged violations of abuse, mistreatment, neglect, exploitation and misappropriation were thoroughly investigated, and did not immediately put effective measures in place to ensure that further misappropriation of resident property, abuse, neglect, or exploitation would not occur while an investigation was in process. […]

• No harm, potential for more than minimal, patternF761Oct 10, 2023

  Based on observation, record review, and interviews during the recertification survey from [DATE] to [DATE], the facility did not ensure safe and appropriate labeling of all medications for 3 ([NAME] Unit, [NAME] Unit, and [NAME] Unit) of 3 units for medication labeling and storage. Specifically, the facility did not ensure insulin Kwik pens on the [NAME] Unit, [NAME] Unit, and [NAME] Unit were labeled with the date they were opened, and the expiration dates after opening. Also, the facility did not ensure nursing staff were knowledgeable regarding how to determine insulin expiration dates after opening. […]

• No harm, potential for more than minimal, patternF585Jun 29, 2021

  Based on observations, interviews and record reviews conducted during the Recertification Survey, the facility did not ensure prompt efforts were made to resolve a grievance for 4 (Resident #'s 56, 143, 170, and #446) of 4 residents reviewed for grievances. Specifically, for Resident #'s 56, 143, 170, and #446, the facility did not ensure there was documented evidence that the resident's complaints that Resident #596 had entered their rooms during the night, startled them from their sleep, and was observed going through their personal belongings and for Resident #56, had left the room with resident #56's personal belongings, was acknowledged by the facility and that the facility was actively working toward providing resolution to their complaints. […]

• No harm, potential for more than minimal, isolatedF600Apr 22, 2025

  Based on record review and interviews conducted during an abbreviated survey (Case #NY00377666), the facility did not ensure the residents' right to be free from abuse for one (1) (Resident #1) of one (1) resident reviewed for abuse. Specifically, on 4/09/2025 at 2:15 AM, Certified Nurse Aide #1 self-reported that they tapped Resident #1 on their right hand when the resident was combative during a shower. This is evidenced by: See cross references of F-609 and F-610. Resident #1 was admitted to the facility with diagnoses of anxiety disorder (mental health condition characterized by excessive fear or anxiety that interferes with daily activities), cognitive communication deficit (communication difficulties that arise from cognitive impairments), and insomnia (sleep disorder that can make… […]