Shirkey Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF692Apr 20, 2022

  Based on observation, record review and interview, the facility failed to notify the resident's physician and to have new interventions in place for a resident with significant unplanned weight loss to prevent the resident from further weight loss for one sampled resident (Resident #56) out of 19 sampled residents. The facility census was 95 residents. The facility did not provide a policy for weight loss. 1. Review of Resident #56's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/18/22 showed: -Brief Interview for Mental Status (BIMS) of 7 (indicates moderate cognitive impairment) -Total dependence on staff for all Activities of Daily Living (ADLs) -Weight of 116 pounds (lbs) -No physician prescribed weight loss. […]

• No harm, potential for more than minimal, widespreadF812Apr 5, 2024

  Based on observations, interviews, and facility policy review, the facility failed to keep the scoops out of food storage bins and ensure stored food was dated. This had the potential to affect 86 of 86 residents who resided in the facility and consumed food prepared from the facility's kitchen. Review of the facility's undated policy titled Resident Food Storage, revealed 1 .Food or beverages brought into the facility for resident consumption will be labeled and dated for monitoring food safety. […]

• No harm, potential for more than minimal, widespreadF868Apr 5, 2024

  Based on interview and record review, the facility failed to have the Medical Director and/or designee attend the last two quarterly QAPI (Quality Assurance and Performance Improvement) committee meetings. Review of the 11/28/23 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked, unable to attend. Review of the 02/20/24 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked as, unable to attend. During an interview on 04/05/24 at 11:53 AM, the QAPI Nurse was asked if the Medical Director or their designee attended the quarterly meetings. The QAPI Nurse stated, He does attend the meetings, but not the last ones. […]

• No harm, potential for more than minimal, patternF550May 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff cared for residents in a dignified manner when they obtained blood sugars and administered insulin in the dining room which affected two of the 18 sampled residents, (Resident #4 and Resident #38). The facility census was 86. Review of the facility's policy, Providing Privacy, dated 4/27/14, showed: - It is the policy of this facility to provide privacy to each and every resident, competent or incompetent; - Facility staff must examine and treat residents in a manner that maintains the privacy of their bodies; - Only authorized staff directly involved in treatment should be present when treatments are given; - People not involved in the care of the individual should not be present without the… […]

• No harm, potential for more than minimal, patternF582May 8, 2025

  Based on interview and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN), the form Centers for Medicare and Medicaid (CMS) - 10055 to two of the three sampled residents (Residents #32 and Resident #139). The SNF ABN provides information to residents/beneficiaries to inform them of their rights that skilled services may not be paid by Medicare and resident or guardian will assume the financial responsibilities. The facility failed to provided the correct Notice of Medicare Noncoverage (NOMNC), which provides information to residents/beneficiaries to inform them of their covered services, and their right to appeal their discharge, for two of the three sampled residents (Resident #32, Resident #190, and Resident 139. […]