Shattuck Nursing Center

In the surveyor’s words

From the most serious findings on record at Shattuck Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Jul 31, 2026

  Based on observation, record review, and interview, the facility failed to ensure medications were safely and securely stored to prevent residents from access to unprescribed medications in resident rooms and for 1 of 2 medication carts observed. The administrator identified 43 residents resided in the facility. Findings: On 07/30/26 at 8:30 a.m., multiple bottles of medications were observed on top of the medication cart sitting by the nurse's station in the center of the building. […]

• No harm, potential for more than minimal, widespreadF838Jun 24, 2022

  Based on interview and record review, the facility failed to ensure a facility risk assessment had been completed and updated. The DON identified 36 residents resided in the facility. Findings: On 06/24/22 at 8:20 a.m., the BOM was asked to provide the most [MEDICATION(S)] facility assessment that had been completed. They provided two binders, an emergency management binder and a Facility Assessment Compliance Tool binder. The FACT book contained an assessment, dated 2017, last signed by the previous administrator. The BOM was asked if there was another date. They stated they would look for another book. On 06/24/22 at 8:32 a.m., the BOM returned and stated they did not find additional information.

• No harm, potential for more than minimal, patternF759Jul 31, 2026

  Based on observation, record review, and interview, the facility's medication error rate was less than 5%. The medication error rate was 11.11%. The administrator identified 43 residents resided in the facility. Findings:1.On 07/30/26 at 8:48 a.m., CMA #1 was observed to administer Resident #20's medications. CMA #1 did not administer their Brimonidine Tartrate Ophthalmic Solution 0.2 % (an eye drop to lower high eye pressure).A medication administration record for Resident #20, dated 07/30/26, showed they were scheduled to be administered Brimonidine Tartrate Ophthalmic Solution 0.2% twice daily at 9:00 a.m. and 9:00 p.m.On 07/30/26 at 8:50 a.m., Resident #20 was heard asking CMA #1 if they would receive their Brimonidine Tartrate Ophthalmic Solution with their morning medications. […]

• No harm, potential for more than minimal, patternF802Jul 31, 2026

  Based on observation, record review, and interview, the facility failed to ensure food service staff was adequately trained on acceptable food temperature for hot and cold foods and on labeling of food and expiration dates.The administrator identified 42 residents received food prepared in the kitchen and one resident received nutrition and hydration solely through a feeding tube. Findings:On 07/28/26 at 12:16 p.m., a tour of the kitchen was conducted. Two wells on the steam table were observed not in working condition. One warmer contained green beans and the temperature measured at 128 degrees F.On 07/28/26 at 12:21 p.m., seven loaves of bread were observed in the kitchen without an expiration date.On 07/29/26 at 11:17 a.m., a tour of the kitchen was conducted. […]

• No harm, potential for more than minimal, patternF812Jul 31, 2026

  Based on observation, record review, and interview, the facility failed to ensure food was maintained at proper temperature controls for 2 of 2 kitchen observations.The administrator identified 42 residents received food prepared in the kitchen and one resident received nutrition and hydration solely through a feeding tube. Findings:On 07/28/26 at 12:16 p.m., a tour of the kitchen was conducted. Two wells on the steam table were observed not in working condition. One warmer contained green beans and the temperature measured at 128 degrees F.On 07/29/26 at 11:17 a.m., a tour of the kitchen was conducted. The following observations were made:a. a large bowl of salad sat on the counter at room temperature,b. […]