Shanoan Springs Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Shanoan Springs Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF803Mar 25, 2026

  On 03/24/26, a past noncompliance Immediate Jeopardy (IJ) situation was determined to have existed related to the facility's failure to ensure Res #3 received a mechanically soft diet without bread per physician order. Res #3 was provided a grilled cheese sandwich and side salad for an evening meal, which resulted in a choking episode requiring emergency services.On 03/24/26 at 3:15 p.m., the OSDH was notified and verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents received physician ordered therapeutic diets.On 03/24/26 at 3:28 p.m., the administrator was notified of the immediate jeopardy situation.Based on observation, record review, and interview, the facility failed to ensure a resident received a physician ordered mechanical soft… […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based on observation and interview, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. The facility identified 48 residents who received their meals from the kitchen. Findings: 1. On 04/15/24 at at 8:21 a.m., an initial tour of the kitchen was conducted. The following observations were made. [NAME] # 1 was observed to take the trash out of the trash can and the trash was taken outside. [NAME] #1 was observed to return to the kitchen and did not wash their hands. [NAME] #1 placed a lid on the chicken, which was on the prep counter in marinade, and then placed the container in the refrigerator. […]

• No harm, potential for more than minimal, patternF578Apr 18, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents were offered to formulate an advance directive, or implemented the choice to formulate an advanced directive, for three (#8, 20, and #42) and posted the correct information regarding code status for one (#2) for 24 residents reviewed for advance directives. The administrator identified 50 residents who resided in the facility. Findings: 1. Res #8 had diagnoses which included atrial fibrillation, COPD, and chronic pain. A quarterly assessment, dated 03/27/24, documented the resident was moderately impaired with cognition and required partial to moderate assistance with most ADLs. On 04/15/24 at 10:55 a.m., a green name tag, indicating full code status, was observed by the resident room. […]

• No harm, potential for more than minimal, patternF600Apr 18, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse and neglect for two (#35 and #40) of three residents sampled for abuse. a. On 10/19/23, an initial Incident Report documented CNA #1 did place their hand over the mouth and nose of the Res #35 on 3 different occasions during a shower. It was also reported that CNA #1 told the resident to shut up. All those involved were suspended until the investigation was complete. CNA #1 was separated from employment immediately and CNA #2 was educated one-on-one related to reporting abuse immediately. […]

• No harm, potential for more than minimal, patternF804Apr 18, 2024

  Based on observation and interview, the facility failed to ensure food was served at an appetizing temperature. The facility identified 48 residents who received their meals from the kitchen. Findings: 1. On 04/17/24 at 11:00 a.m., the menu was observed and documented the noon meal was to have been french onion pork chops, pork gravy, white cheddar mac and cheese, green peas, wheat dinner roll, margarine, apple [NAME], milk, and coffee. On 04/17/24 at 11:10 a.m., [NAME] #1 was observed to obtain the temperature of the pork chops when they were removed form the oven. The temperature at that time was 184 degrees F. The pork chops were place in a deep pan and then placed on the steam table. The other food items were not observed to be temped before placing on the steam table. […]