Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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.
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 | ★★★★★ | 9 | 2 |
| Westwood Health And Rehabilitation | 5 mi | ★★★★★ | 18 | 0 |
| Westchester Manor At Providence Place | 5.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.