The Shannon Gray Rehabilitation & Recovery Center

In the surveyor’s words

From the most serious findings on record at The Shannon Gray Rehabilitation & Recovery Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Jun 26, 2026

  Based on observations and staff interviews, the facility failed to remove expired medications stored in 1 of 3 medication rooms and 1 of 6 medication carts reviewed for medication storage (Over the Counter (OTC) Medication Storage Room and Medication Cart for 800 hall).The findings included:a. An observation of the Over the Counter Medication Storage Room was conducted on 6/24/2026 at 9:33 AM in the presence of the Supply Coordinator. The observation revealed the following expired medications:-Two bottles of vitamin D-3 10 micrograms (mcg) film-coated tablets (a dietary supplement medication) with an expiration date of 9/2025. Both bottles were opened and observed without labels indicating their opening dates. One bottle contained 65 tablets, and the second bottle contained 34 tablets. […]

• No harm, potential for more than minimal, patternF880Jan 11, 2024

  Based on observation, record review and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide (NA) #1 and NA #2 failed to remove their masks before exiting a COVID-19 isolation room for 2 of 7 residents reviewed for infection control. (Resident #10 and Resident #24) Findings included: Record review of the Facility Infection Prevention and Control Program Policy last revised 7/13/23 revealed the program outlines strategies designed to reduce the risk of transmission of infectious agents among healthcare workers, residents, and visitors. […]

• No harm, potential for more than minimal, isolatedF550Jun 26, 2026

  Based on record review, staff and resident interviews, the facility failed to provide a resident with dignity and respect when Nurse Aide (NA) #1 confronted Resident #77 about reporting her and making false accusations to management. Resident #77 stated this made her feel fearful and treated unfairly. The facility also failed to provide dignity and respect to Resident #35 when NA #2 spoke smack and not very nice to the resident. Resident #35 stated this made him feel frustrated. This occurred for 2 of 4 residents reviewed for dignity (Resident #77 and Resident #35). […]

• No harm, potential for more than minimal, isolatedF880Jun 26, 2026

  Based on observation, staff and Physician interviews, and record review, the facility failed to implement their infection control policy and procedure, when a Nurse Aide (NA) failed to perform hand hygiene after the completion of catheter care for Resident #36 who was on Enhanced Barrier Precautions (EBP) for an indwelling catheter. This deficiency occurred for 1 of 4 staff members reviewed for infection control practices (NA #4). The findings included:A review of the facility's policy and procedure titled Infection Control in Long Term Care (LTC) Policy dated April 2026 read in part:Use a piece of personal protective equipment one-time-then throw it away.Change gloves when they are soiled, and when moving from a contaminated to clean area of the body.A review of facility's Infection… […]

• No harm, potential for more than minimal, isolatedF627Nov 19, 2025

  Based on facility record review, hospital emergency department record review, and Resident, Responsible Party, staff, and Medical Director Interviews, the facility failed to ensure a resident received the medications ordered for her by the physician at discharge from the facility. At the time of discharge on [DATE] medications belonging to another resident were inadvertently provided to Resident #1. On 10/21/25 the Responsible Party looked at the medication packaging and realized the medications were prescribed for another resident and she was taken to the Emergency Department (ED) for evaluation. The ED Provider Note stated Resident #1 had no complaints, but the RP stated she was shaky over the last few days. […]