Shea Post Acute Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF658Jun 2, 2023

  Based on review of records, staff interviews and review of policies and procedures, the facility failed to ensure that medications were administered per physician ordered parameters for one resident (#194); and failed to ensure medications were not left at the bedside for one resident (#83). The facility census was 94, and the sample was 19 residents. The deficient practice has the potential for residents not receiving medications as ordered by the physician. Findings include: -Resident #194 was admitted on [DATE] with diagnoses of right arm humerus fracture, muscle weakness, hemiplegia and hemiparesis, and protein-calorie malnutrition. The care plan dated May 24, 2023 included the resident was prescribed with an opioid for acute on chronic pain. […]

• No harm, potential for more than minimal, patternF658Apr 14, 2022

  Based on clinical record reviews, resident and staff interviews, and policy reviews, the facility failed to ensure care and services provided met professional standards for 4 residents, by failing to ensure one resident (#4) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #83) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The sample size was 20. The deficient practice could negatively impact residents' care. Findings include: -Resident #4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF886Apr 14, 2022

  Based on staff interviews, review of facility documentation, policy and procedure, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule related to Long-Term Care (LTC) Facility Testing Requirements and COVID-19 Health Care Staff Vaccination, the facility failed to ensure three unvaccinated contract staff were tested based on parameters set for COVID-19 testing frequency. The deficient practice can result in COVID positive staff not being identified and the spread of infection to residents and staff. Findings include: Review of facility documentation revealed the facility had approximately 37 contract staff on board. […]

• No harm, potential for more than minimal, isolatedF584Aug 7, 2026

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure that laundry for one out of five residents (#16) was handled, stored and processed to ensure a safe, clean, comfortable homelike environment. The universe was 98. The deficient practice could result in room odors, lack of available clothing for the resident, a potential infection control issue and psychosocial harm.Findings include:Resident #16 was admitted on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and right dominant side, abnormalities of gait and mobility, related falls, and need for assistance with personal care.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of… […]

• No harm, potential for more than minimal, isolatedF761Aug 7, 2026

  Based on observations, interviews, and a review of facility policy and procedure, the facility failed to ensure all drugs and biologicals were secure and inaccessible to unauthorized staff and residents when a medication cart was left unattended. The sample was 23 residents, and the universe was 109 residents. The deficient practice could result in unauthorized persons having unrestricted access to medications and medical supplies. Findings include:An observation was conducted on August 6, 2026 at 2:10 p.m. in hallway A. Medication cart A1 was observed to be unlocked when Registered Nurse (RN/staff #50) walked away from the medication cart and down the hallway connecting hallway A and hallway B. […]