Shawnee Post Acute Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Shawnee Post Acute Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF692Mar 27, 2024

  TThe facility identified a census of 80 residents. The sample included 18 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to obtain accurate weights and verify weight changes related to Resident (R)28's physician-ordered weekly weights to effectively monitor weight trends and identify concerns before a significant weight loss occurred. The facility further failed to ensure staff served R28 a diet he could safely consume. As a result of the deficient practices, R28 had a significant unplanned weight loss of 28.38 percent (%) within one month. […]

• Actual harm, isolatedF692Oct 5, 2022

  The facility had a census of 79 residents. The sample included 17 residents with seven reviewed for nutrition. Based on observation, interview, and record review, the facility failed to respond to an unplanned, ongoing weight loss and failed to identify and implement further interventions to prevent weight loss for Resident (R)22 who had a significant unplanned weight loss of 14.29 percent ( in six months. Findings included: -The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] recorded R22 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. […]

• No harm, potential for more than minimal, widespreadF880Feb 18, 2026

  The facility had a census of 79 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to ensure staff performed appropriate glove changing and hand hygiene for two residents, Resident (R) 18 and R52, when they did not remove their soiled gloves after incontinence care and continued to touch other surfaces and resident belongings.Findings included:- On 02/17/26 at 07:40 AM, Certified Nurse Aide M pushed R18 in her wheelchair to the bathroom and put on clean gloves. CNA M locked the wheelchair, put her right hand under R18's left arm, and R18 grabbed the bar on the wall by the toilet and stood up. CNA M pulled down R18's pants and incontinence brief, and R18 sat down on the toilet. […]

• No harm, potential for more than minimal, widespreadF801Mar 27, 2024

  The facility identified a census of 80 residents. The facility had one main kitchen and four dining areas. Based on observation, record review and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 03/26/24 at 11:28 AM Dietary BB stated he and Dietary CC had not completed the course yet to become a CDM. Dietary BB stated he and Dietary CC had begun the courses. […]

• No harm, potential for more than minimal, widespreadF941Mar 27, 2024

  The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure direct care staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life. Findings Included: - On 03/27/24 at 11:40 AM a review of the facility's training for Certified Nurses Aid (CNA) PP, CNA QQ, Licensed Nurse (LN) L, LN NN, and LN OO revealed the following: CNA PP's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she passed abuse, neglect, and exploitation (ANE) and a mental health course. CNA QQ's facility-provided credentialling file lacked documented and completed training completed for communication. […]