Shawnee Gardens Healthcare & Rehab Center
SHAWNEE GARDENS HEALTHCARE & REHAB CENTER in SHAWNEE, KS — inspection on February 19, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observation, record review, and interviews, the facility to implement effective behavioral monitoring and interventions related to Resident (R) 1's ongoing sexual behaviors toward female residents.
This deficient practice placed R1 at risk for continued behavioral episodes and unmet care needs.
Findings Included:
- The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of sexual behaviors related to psychiatric illness.
R1's Quarterly Minimum Data Set (MDS) completed 12/15/24 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment.
The MDS noted he had verbal and physical aggression one to three days weekly.
The MDS noted he had rejection of care behaviors one to three days weekly.
The MDS noted he was independent with transfers, bed mobility, bathing, toileting, and walking. R1's MDS noted no sexual behaviors.
R1's Cognitive Loss Care Area Assessment (CAA) completed 06/11/24 noted he had impaired cognition related to his medical diagnoses.
The CAA noted he required reorientation, reminders, and reassurance to make sense of things.
The CAA noted a care plan was implemented with interventions and monitoring to reduce the risks.
R1's Behavioral Symptoms CAA was not triggered.
R1's Care Plan initiated on 10/25/23 noted he was admitted to the long-term care unit due to his medical diagnoses.
The plan noted he exhibited sexually inappropriate behaviors related to his psychiatric illness (03/04/24).
The plan instructed staff to explain and reinforce to R1 why his behaviors were inappropriate or unacceptable (03/04/24).
The plan instructed staff to educate and collaborate with R1 to find successful coping and interaction strategies (03/04/24).
The plan instructed staff to administer and monitor his medication's side effects and effectiveness (03/04/24).
The plan revealed that R1 was moved to another unit due to exhibiting sexually inappropriate behaviors (02/08/24).
The plan lacked information related to his sexual behaviors towards female residents, required supervision around female residents, and required monitoring while out of his room as noted in progress notes.
The plan lacked specific triggers and coping strategies needed to prevent his sexual behaviors.
175267
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 175267 B.
Wing 02/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216
The facility failed to ensure cognitively impaired R2 remained free from abuse when the facility failed to prevent an episode of resident-to-resident sexual abuse.
This placed R2 at risk for ongoing and/or unidentified abuse and mistreatment based on the reasonable person concept, this deficient practice resulted in feelings of fear for R2 and placed R2 at risk for further psychosocial harm, intimidation, and neglect.
The facility failed to identify and implement preventative interventions related to Resident (R)1's sexual behaviors upon moving him to a new unit.
This deficient practice placed 19 female residents at risk for sexual abuse.
On 02/19/25 at 03:31 PM, Administrative Staff A was provided a copy of the IJ template and notified of the facility's failure to prevent the sexual abuse of R2, the facility additionally placed 19 other female residents at risk for sexual abuse after moving R1 to another unit without addressing his sexual behaviors.
The facility provided an acceptable plan for the removal of the immediacy on 02/19/25 at 04:30PM which included the following:
175267
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 175267 B.
Wing 02/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216