Shawnee Manor

In the surveyor’s words

From the most serious findings on record at Shawnee Manor, in the surveyor’s own words.

• Actual harm, isolatedF760Jan 23, 2023

  Based on medical record review, review of a medication error report/investigation and staff and resident interviews, the facility failed to ensure a resident received medications as ordered resulting in a significant medication error. This resulted in Actual Harm when Resident #45 was given another resident's (#01) medications on 01/05/23 and was subsequently admitted to the hospital with encephalopathy (altered brain function) due to the medication administration error. This affected one (#45) out of four residents reviewed for medications. […]

• Actual harm, isolatedF600Jan 28, 2022

  Based on medical record review, observation of Snapchat video, resident interview, family interview, staff interview, review of the facility's Self-Reported Incidents (SRIs), review of facility handbook, and review of facility policy, the facility failed to ensure residents were protected from mental abuse by staff. This affected one (#11) of three residents reviewed for abuse and exploitation. This resulted in actual harm for Resident #11 when a staff member posted a video on the social media platform Snapchat in which Resident #11 could be identified sitting on the toilet with feces on her leg, including a statement that the situation made the staff member pissed. […]

• No harm, potential for more than minimal, widespreadF868Aug 18, 2022

  Based on review of Quality Assessment and Assurance (QAA) sign-in documents and staff interview, the facility failed to ensure all required members attended a QAA meeting quarterly. This had the potential to affected all 82 residents. The facility census was 82. Findings include: Review of the QAA sign-in documents for July 2022 revealed the medical director did not attending the QAA meeting on 07/28/22. The last meeting the medical director attended was on 04/29/22. Interview on 08/18/22 at 2:50 P.M. with the Administrator verified the medical director did not attend QAA meeting on 07/28/22.

• No harm, potential for more than minimal, widespreadF880Jan 28, 2022

  Based on observation, staff interview, review of facility policy, and review of the Center for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff who tested positive for COVID-19 did not return to the resident unit, wore N95 respirator's properly, and performed hand hygiene when handling the N95 respirator. This had the potential to affect all residents in the facility. The facility census was 84. Findings include: Observation on 01/24/22 at 9:50 A.M. found Administrative Assistant (AA) #546 interviewing State tested Nursing Assistant (STNA) #542 regarding contact tracing and her contact and interactions with residents. While the questionnaire was being completed STNA #542 was observed to have her N95 respirator on with both straps low on her neck. […]

• No harm, potential for more than minimal, widespreadF880Sep 24, 2021

  Based on observations, review of infection control logs, staff interviews, and review of the facility policies, the facility failed to ensure all staff wore eye protection in resident areas and instructed residents to wear face coverings when outside of their rooms. The facility also failed to ensure hand sanitation and gloves were worn when obtaining blood for a finger stick blood sugar (FSBS) for one (#9) resident and administering eye drops for Resident #85. In addition, the facility failed to ensure appropriate incontinent care was provided for Resident #28, per facility policy. […]