Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Shannon Gray Rehabilitation & Recovery Center during CMS and state inspections, most recent first.
Expired medications were found in the OTC medication storage room and on a medication cart, including opened vitamin D bottles without opening dates, triple antibiotic ointment, hydrocodone/acetaminophen, ondansetron, benzonatate, mycophenolate, and prednisone. The Supply Coordinator said expired OTC meds should be given to her for disposal, while an RN stated she likely overlooked PRN meds in the bottom drawer of the cart. The DON said staff were instructed to check carts for expired meds before use, but the expired medications were still present.
Failure to Maintain Resident Dignity and Respect: Two cognitively intact residents reported disrespectful interactions with NAs. One resident said an NA confronted her about complaints made to management and accused her of false accusations, leaving her fearful and treated unfairly. Another resident said a different NA spoke in a rough, belittling manner and never said anything kind, which left him frustrated.
A Nurse Aide failed to follow infection control practices during indwelling catheter care for a resident on EBP. After completing catheter care, the aide kept contaminated gloves on while assisting the resident, touching the resident’s personal items, and adjusting linens and the bed before later removing the gloves and performing hand hygiene. The aide said she should have changed gloves, while the Unit Coordinator and Physician stated the gloves should have been removed and hand hygiene performed before contact with the resident or personal items.
Resident Council grievances about weekend housekeeping and unlabeled or missing clothing items were not effectively resolved or communicated. Meeting minutes documented repeated concerns over two months, and residents stated their grievances were not being addressed. The Activities Director said she relied on others to handle and report back on grievances, while the DON was unaware of any Resident Council grievance process and the Administrator could not explain how the concerns were being addressed.
A resident was discharged and inadvertently sent home with another resident's medications after a rushed handoff during shift change. The responsible party administered the incorrect medications for several days before noticing the error, leading to an ED visit where the resident was found to be clinically stable. The error was confirmed through interviews and record review, with both nurses involved unable to explain how the wrong medications were included.
Two residents did not have their MDS assessments accurately coded: one with an active psychiatric diagnosis was not coded for PTSD, and another with urinary retention was not coded for an indwelling urinary catheter despite documentation and staff confirmation. Staff acknowledged these oversights and the administrator confirmed the expectation for accurate MDS coding.
A resident with a stage 3 pressure ulcer had a positive wound culture result posted to the EMR, but due to staff confusion over a recent EMR process change, the result was not communicated to the Wound Care Physician for three days, delaying antibiotic treatment. The delay occurred because nursing staff and the DON were unaware that lab results were now delivered electronically and did not receive notification, resulting in the physician only being informed during a subsequent visit.
A wound care nurse did not perform hand hygiene or change gloves between the dirty and clean portions of a pressure ulcer dressing change for a resident, instead using the same gloves throughout the procedure. This practice was inconsistent with the facility's infection control policy, which requires hand hygiene and glove changes when moving from a dirty to a clean site during wound care.
Expired Medications Found in OTC Storage Room and Medication Cart
Penalty
Summary
Expired drugs and biologicals were found stored in the facility’s medication areas, including the Over the Counter (OTC) Medication Storage Room and the medication cart for the 800 hall. In the OTC Medication Storage Room, surveyors observed two opened bottles of vitamin D-3 10 mcg tablets with an expiration date of 9/2025 and no opening dates on the labels, along with one tube of triple antibiotic ointment with an expiration date of 10/2025. The Supply Coordinator confirmed the expiration dates and stated a staff member must have returned the opened vitamin D bottles to the storage room without her knowledge. She also stated staff should give expired OTC medications to her for disposal and that she typically checked the room one to two times per week, with the last check occurring on 6/17/2026. On the 800 hall medication cart, surveyors found expired medications including 20 hydrocodone/acetaminophen 5 mg/325 mg tablets, 2 ondansetron 4 mg tablets, 15 benzonatate 200 mg capsules, 29 mycophenolate 500 mg tablets, and 5 prednisone 20 mg tablets. Nurse #2 confirmed the expiration dates and stated she last checked the cart approximately two weeks earlier, although she had been told pharmacy checked it on 6/19/2026. She said she likely overlooked the medications in the bottom drawer because they were PRN medications and stated narcotic medications would be sent back to the pharmacy for disposal. The DON stated staff were educated to check medication carts for expired medications prior to use, but expired medications remained in the cart and she believed several were PRN medications that had been overlooked.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to provide dignity and respect when a nurse aide confronted a cognitively intact resident about reporting her to management and making false accusations. The resident, who was dependent for toileting and needed partial to moderate assistance with bathing, stated the confrontation made her feel fearful and treated unfairly. The nurse aide acknowledged she returned to the resident after the resident spoke with upper management and confronted her because she did not appreciate being reported, while the unit coordinator and unit manager were aware of the resident’s concerns but did not document the event or escalate it to the DON or Administrator. The resident reported that the nurse aide had previously spoken harshly and did not spend time with her, and that the aide told her she was making false accusations. The unit coordinator confirmed the resident had complained that the aide was not taking time with her and was speaking harshly, and the aide was shocked by the complaint. The Administrator stated the aide should not have spoken to the resident about the meeting with the unit coordinator, and the DON stated the resident’s perspective was the reality. The facility also failed to provide dignity and respect to another cognitively intact resident with a stroke diagnosis when a different nurse aide spoke to him in a rough and not very nice manner. The resident stated the aide had never said a nice word to him and described her comments as “talking smack,” including telling him, if he could use the bathroom, she would not have to keep coming in. The resident said the aide’s communication was rough and that she kept poking at him, which left him frustrated.
Failure to Perform Hand Hygiene After Catheter Care
Penalty
Summary
The facility failed to implement its infection control policy and procedure when a Nurse Aide did not perform hand hygiene after completing indwelling urinary catheter care for Resident #36, who was on Enhanced Barrier Precautions for an indwelling catheter. During the observation, the Nurse Aide performed catheter care while wearing gloves and a gown, stabilized the catheter tubing, and cleaned the exposed catheter line with soap and water. After finishing the catheter care, the Nurse Aide assisted the resident to turn onto her side, reattached her brief, positioned her for comfort, adjusted the linens and pillow, and reset the bed without removing her gloves or performing hand hygiene before touching the resident or the resident’s personal items. The Nurse Aide then picked up the wash basin and washcloths and went to the bathroom to empty the basin, removed her gloves there, and performed hand hygiene before leaving the room. In interview, the Nurse Aide stated she should have changed her gloves after catheter care before touching the resident and was unsure of her last catheter care training. Unit Coordinator #2 stated the proper procedure was to remove contaminated gloves immediately after catheter care, perform hand hygiene, and then put on clean gloves before touching the resident or personal items. The DON stated it was acceptable for the Nurse Aide to touch the resident and the resident’s personal items without removing gloves or performing hand hygiene, while the Physician stated that doing so was not consistent with appropriate infection control standards.
Resident Council Grievances Not Addressed
Penalty
Summary
The facility failed to implement an effective process to resolve and communicate its efforts to address repeated Resident Council concerns about lack of weekend housekeeping and unlabeled or missing clothing items. Review of Resident Council meeting minutes showed that in May 2026 residents raised concerns about needing more frequent housekeeping visits on the weekend and multiple unlabeled or missing clothing items. In June 2026, the minutes again documented concerns about needing more housekeeping on the weekend for trash removal and multiple unlabeled or missing clothing items, but there was no follow-up noted in the minutes. During the 06/24/2026 Resident Council meeting, residents voiced that their grievances were not being addressed, and the Resident Council President stated housekeeping and laundry had remained a concern for the past two months without resolution. In interviews, the Resident Council President said housekeeping was not seen on weekends and that resident clothing was not being returned when laundry services were provided, with residents obtaining clothes from the donation area. The Activities Director stated she would either ask a staff member to address a grievance immediately or verbally inform the Administrator, DON, or Social Worker, but she did not follow up herself and expected others to inform her of the outcome. The DON stated she was unaware there was a process for grievances related to Resident Council, and the Administrator was unable to explain how Resident Council grievances were being addressed.
Resident Discharged with Another Resident's Medications Due to Discharge Process Error
Penalty
Summary
A deficiency occurred when a resident was discharged from the facility and was inadvertently provided with medications belonging to another resident. The error was discovered after the responsible party (RP) administered the incorrect medications for four days before noticing that the medication packaging had another resident's name. The RP reported that the resident became confused and exhibited jerking motions in her arms, prompting a visit to the emergency department (ED) for evaluation. The ED assessment found the resident to be clinically stable, with normal laboratory and electrocardiogram results, and no evidence of a major medication reaction. The incident was precipitated by a rushed discharge process during a shift change. The RP took the resident to the car without notifying the nursing staff, and when prompted, returned to the facility to receive discharge instructions and medications. Two nurses were involved in reviewing and handing over the medications, but neither identified that medications belonging to another resident were included in the discharge bag. Both nurses confirmed that the resident's narcotic pain medication was properly counted and signed out, but could not explain how the other resident's medications were included. Interviews with the resident, RP, nursing staff, and the medical director confirmed the sequence of events. The resident did not recall the ED visit, and the RP admitted to not reviewing the medication instructions provided by the facility, instead relying on the medication cards. The medical director and DON acknowledged that the error occurred during the discharge process and was only identified after the hospital notified the facility. The facility's records and interviews confirmed that the resident was cognitively intact at admission and that the error was not detected until after discharge.
Inaccurate MDS Coding for Diagnoses and Catheter Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of active diagnoses and urinary catheter use. For one resident with a history of schizoaffective disorder and an active diagnosis of Post-Traumatic Stress Disorder (PTSD) since August 2023, the annual MDS assessment did not reflect the active PTSD diagnosis in the Psychiatric/Mood Disorder section. The MDS nurse acknowledged this omission as an oversight during an interview. For another resident admitted with urinary retention, the quarterly MDS assessment did not indicate the presence of an indwelling urinary catheter, despite the resident's care plan documenting its use. Staff interviews confirmed that the resident had an indwelling catheter during the assessment period, and the MDS nurse admitted that the catheter should have been coded on the MDS. In both cases, the administrator stated that accurate MDS coding was expected.
Failure to Notify Physician of Positive Wound Culture Result Due to EMR Process Change
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify the Wound Care Physician of a positive wound culture lab result for a resident with a stage 3 pressure ulcer. The resident, who had dementia and was at risk for pressure ulcers, had a wound culture ordered due to suspected infection. The lab result, which identified proteus mirabilis, was posted directly into the resident's electronic medical record (EMR) on the day it was finalized. However, the result was not communicated to the physician until three days later, delaying the initiation of antibiotic therapy. The delay was due to confusion and lack of awareness among staff regarding the new process for receiving lab results through the EMR, which had recently replaced the previous paper-based system. The nurse assigned to the resident on the day the result was posted was unaware that lab results were now delivered electronically and did not receive any notification of the new result. The Wound Care Nurse, who was absent at the time, expected the assigned nurse to address the result, while the Director of Nursing (DON) was also unaware of the EMR process and continued to rely on a manual logbook and printed results. As a result, the wound culture result was not reviewed or reported to the physician until the Wound Care Nurse returned and printed the report from the vendor site. The physician confirmed that he was not informed of the result until his next visit, at which point antibiotics were ordered. The delay in notification and treatment was directly related to the facility's failure to adapt to the new EMR system and ensure staff were informed of and following the updated process for lab result review and provider notification.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
The facility failed to follow its infection control policy regarding hand hygiene and glove use during wound care for a resident with a stage 3 pressure ulcer on the right buttock. During an observed dressing change, the wound care nurse washed her hands and donned gloves before removing the soiled dressing and cleansing the wound. However, she did not perform hand hygiene or change gloves after handling the dirty dressing and before applying the clean treatment and new dressing. The nurse continued the procedure with the same gloves, contrary to the facility's infection control policy, which requires hand hygiene and glove changes when moving from a dirty to a clean site during resident care. The wound care nurse stated that she only changed gloves between wounds if a resident had more than one wound, and believed it was acceptable to use the same gloves for a single wound. The administrator and facility owner initially supported this practice, citing a misunderstanding of infection control recommendations. The wound care physician, however, confirmed that hand hygiene and glove changes are expected between the dirty and clean portions of wound care, regardless of the number of wounds. The facility's infection control policy, last updated on 10/22/24, also specifies these requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jamestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maryfield Nursing Home | 0.5 mi | ★★★★★ | 1 | 0 |
| Adams Farm Living & Rehabilitation | 3.5 mi | ★★★★★ | 1 | 0 |
| Meridian Center | 3.9 mi | ★★★★★ | 7 | 0 |
| Westwood Health And Rehabilitation | 5 mi | ★★★★★ | 18 | 0 |
| Westchester Manor At Providence Place | 5.6 mi | ★★★★★ | 0 | 0 |
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