Shandin Hills Behavior Therapy Center

In the surveyor’s words

From the most serious findings on record at Shandin Hills Behavior Therapy Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 30, 2023

  Based on observation, interview, and record review, the facility failed to provide a safe environment with adequate monitoring and supervision for one out of the three residents (Resident 1) with impaired impulse control, insight, and judgment. Resident 1 had a psychiatric diagnosis of severe mental and emotional disorder and managed to elope (run away secretly) from the facility without staff's knowledge. This failure resulted in Resident 1 eloping from the facility on February 6, 2023, and Resident 1 was not found. Resident 1 had a history of elopement resolved on April 26, 2019. This current elopement has the potential for Resident 1 to sustain injury, fall, exposure to heat, cold, dehydration, drowning, getting hit by car and even death. […]

• No harm, potential for more than minimal, widespreadF812Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food safety when: 1. A turkey meat product wrapped in foil was in the freezer, uncovered in a tray.2. One open box of fish filet was in the freezer with the inner plastic bag not properly sealed.3. One open box of frozen chocolate chip cookie dough had the inner plastic bag left open.4. Heavy grease, carbonized food residue (burnt food that has hardened and turned black due to heat and was not cleaned from surfaces) and burnt buildup were observed on cooking surfaces, ovens, and drip trays.5. Visible grease accumulation was observed on interior and exterior oven surfaces.6. […]

• No harm, potential for more than minimal, widespreadF803Nov 15, 2024

  Based on observation, interview, and record review, the facility failed to follow their daily approved menu for lunch when, on November 12, 2024, Dietary [NAME] served a mixture of lettuce, tomato, and cheese together to serve with tacos and used a #24 scoop (1.33 ounces or 2-2/3 tablespoons), instead of 1/4 cup (4 tablespoons) shredded lettuce and diced tomato topping and 1 tablespoon of shredded cheddar cheese. This failure had the potential for residents to compromise their nutritional status when menus are not followed for 78 of 78 medically compromised residents who received food from the kitchen. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. There were eight outdated cups of prune juice found in the kitchen refrigerator, and one box of outdated saltine crackers was found in the dry food storage and were available for use. 2. There were food crumbs and trash under the stove. These failures had the potential to expose 77 highly susceptible residents who received food from the kitchen to foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). Findings: 1. […]

• No harm, potential for more than minimal, widespreadF880Nov 3, 2023

  Based on observation, interview, and record review, the facility failed to implement the water management plan in accordance with their own policy and procedure. This failure had the potential to result in causing water borne illness(illness caused by ingestion of contaminated water) to 77 residents in the facility. Findings: During an interview, on November 2, 2023, at 1:00 PM, with the Maintenance Supervisor 1 (MS 1), the MS 1 stated he was not following the water management plan as per facility policy and procedure except for checking the water temperature. […]