Shawnee Gardens Healthcare & Rehab Center

In the surveyor’s words

From the most serious findings on record at Shawnee Gardens Healthcare & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 19, 2025

  The facility identified a census of 117 residents. The sample included eight residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to prevent an episode of resident-to-resident sexual abuse for cognitively impaired Resident (R) 2. On 02/08/25, facility staff witnessed R1 groping R2's nipples, breast, and buttocks while both were seated at the dinner table on the locked unit for cognitively impaired residents. R2 voiced she did not consent to R1 touching her. […]

• Actual harm, isolatedF563Jun 11, 2025

  The facility identified a census of 116. The sample included five residents, with one resident reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 was able to exercise her right to receive visitors of their choosing at the time of R1's choice. This deficient practice affected R1's psychosocial well-being and placed R1 at risk for impaired resident rights and social isolation. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and dementia (a progressive mental disorder characterized by failing memory and… […]

• Actual harm, isolatedF684Jun 11, 2025

  The facility identified a census of 116 residents. The sample included five residents. Based on record review and interviews, the facility failed to obtain a physician-ordered urinalysis (UA- lab analysis of urine) and other laboratory tests ordered on 06/03/25. The facility further failed to notify the physician related to the delay in obtaining the ordered UA and laboratory tests for Resident (R) 2. R2 had fallen on 06/05/25 and 06/06/25, and R2 had a change in condition on 06/07/25. […]

• Actual harm, isolatedF610Feb 19, 2025

  The facility identified a census of 117 residents, with eight residents sampled, including two residents reviewed for abuse. Based on observation, record review, and interviews, the facility failed to implement effective preventative interventions related to Resident (R)1's sexual behaviors to protect the female residents in the facility including R2 (See F600). This failure placed 19 female residents at risk. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),… […]

• Actual harm, isolatedF689May 1, 2024

  The facility identified a census of 120 residents. The sample included three residents reviewed for falls. Based on record review and interviews, the facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for Resident (R) 1, who was cognitively impaired. The facility further failed to ensure R1 received post-fall care including neurological evaluations and nursing assessments following an unwitnessed fall that resulted in obvious head trauma on 04/27/24 at 03:28 AM. R1 was later sent out to the hospital on 04/27/24 at 08:45 AM where he was found to have nasal bone fractures and multiple rib fractures. […]