Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Shawneespring Health Care Center during CMS and state inspections, most recent first.
Food Storage and Facial Hair Restraint Violations: Milk crates were observed stored directly on the floor in the walk-in refrigerator, contrary to facility policy requiring food to be kept at least 6 inches above the floor. In addition, a staff member preparing pureed food and an FSA serving food had facial hair that was not fully covered with beard restraints, despite policy requiring hair and beard restraints for kitchen and serving staff.
Staff unlocked and searched a resident's locked nightstand drawer without the resident present or obtaining consent, removing a vape pen from inside. The Maintenance Director provided the key and unlocked the drawer at the request of the UM, who then took the vape pen, while an OTA was also present. The OTA had previously reported the vape pen to therapy leadership and informed the UM but did not seek the resident's permission to search or retrieve items, and the resident did not request that staff retrieve anything. The DON later discovered the vape pen on their desk and had not discussed the search with the resident. The facility's smoking policy states that monitoring residents' rooms and belongings for smoking materials must be done in a way that does not violate resident privacy.
Survey Results Not Readily Accessible: Residents stated they did not know where the State Inspection results were located, and staff at the main entrance/reception desk could not identify the Survey Results binder or its location. No signage was posted at the entrance or in the activities room, where the binder was later found on a counter. The facility handbook required the most recent survey results to be posted in a place readily accessible to residents, family members, and legal representatives.
A resident with a history of constipation and other comorbidities had a care plan and physician order for daily Miralax, with interventions requiring monitoring and recording of bowel movements. Bowel tracking showed a small bowel movement followed by five consecutive days without a documented BM, but nursing staff did not implement the facility’s bowel monitoring policy, which required review and intervention after three days without a BM, nor did they notify a clinician at that point. During this period, the resident developed abdominal pain, pain on palpation, coughing up mucus, and labored breathing, leading an MD to order transfer to the ED. Hospital CTA revealed a large fecal impaction with colonic wall thickening and pneumoperitoneum consistent with bowel perforation, likely related to stercoral colitis; the resident was admitted and later died, with cardiac respiratory arrest listed as the cause of death. The MD and NP reported they were not informed when the resident had gone three days without a BM, despite the expectation for notification at that time.
A cognitively intact resident with psychosis, hallucinations, Parkinson's disease, and neurocognitive disorder with Lewy bodies told a PASRR assessor that someone had grabbed his penis. A social worker notified the administrator, who documented the allegation and then, after speaking with the resident’s son, concluded it was likely a hallucination and chose not to investigate or file an SRI. Review of records showed no sexual abuse allegation was reported to the state survey agency, despite facility policy requiring that any abuse allegation be reported within two hours. The DON confirmed the administrator had been informed of the allegation, and the administrator acknowledged the facility did not follow its abuse policy.
A resident with psychosis, hallucinations, Parkinson's disease, and neurocognitive disorder, but assessed as cognitively intact on the MDS, told a PASRR assessor that someone had grabbed his penis. The SW and DON confirmed that the allegation was reported to the Administrator. After speaking with the resident and his son, the Administrator concluded the report was likely a hallucination, did not initiate an SRI, and conducted no further investigation. Review of SRI logs showed no sexual abuse reports for this resident, and the Administrator acknowledged that the facility did not follow its abuse policy requiring prompt reporting of all abuse allegations to the State Survey Agency.
Food Storage and Facial Hair Restraint Violations
Penalty
Summary
The facility failed to store, prepare, and serve food in a manner that prevents the potential spread of food-borne illness to residents. During observation in the kitchen, three crates of milk were found sitting directly on the floor in the walk-in refrigerator, and the Dietary Manager confirmed the milk delivery had been received the day before. Facility policy required all foods stored in the walk-in refrigerator and freezer to be kept at least six inches above the floor on shelves, racks, dollies, or other surfaces that allow thorough cleaning. In addition, a staff member preparing pureed food had facial hair measuring about one-half inch in length and was not covering his mustache with a facial hair restraint, and another staff member obtaining food temperatures and serving food had a beard and mustache of about one-half inch in length that was not fully covered with a facial hair restraint. The Regional Chef, the staff member preparing food, the Food Service Assistant, and the Dietary Manager confirmed these observations. Facility policy required hair and beard restraints to be worn by kitchen staff and serving staff.
Failure to Obtain Resident Consent Before Searching Locked Personal Belongings
Penalty
Summary
A resident with COPD with acute exacerbation and tobacco use, admitted on 11/15/25, had a locked nightstand drawer containing a vape pen. On 03/02/26 at 11:27 A.M., the Maintenance Director entered the resident's room with the Unit Manager (UM) and an Occupational Therapy Assistant (OTA) present near the bedside stand. The Maintenance Director unlocked the resident's locked nightstand drawer and the UM removed the vape pen from inside. The resident was not in the room or nearby at the time. The UM confirmed removing the vape pen from the locked drawer and acknowledged that the resident was not present and that she did not obtain the resident's consent to search the property. The Maintenance Director confirmed providing the key, that the drawer was unlocked at the UM's request, and that no consent was obtained from the resident. The OTA reported notifying the Director of Therapy and verbally informing the UM that the resident had a vape pen, and confirmed the resident was not in the room when the vape pen was removed. The OTA further confirmed they were not asked by the resident to retrieve anything from the nightstand and did not ask the resident for consent to search the property. The DON stated they were unaware at the time that the resident's property had been searched and later found the vape pen on their desk with a note, and confirmed they had not spoken with the resident about the search. The resident reported that staff took the vape pen from the locked drawer while the resident was at therapy and confirmed that no one asked for consent to search the property or to retrieve anything from the room. Facility policy on resident smoking states that staff will monitor rooms and belongings of residents who smoke for smoking materials in a manner that does not violate the resident's right to privacy.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives. During a Resident Council Task Meeting interview, Residents #14, #86, and #119 stated they had no knowledge of where the State Inspection results were located. During an observation and interview at the main entrance/receptionist desk, there was no signage directing people to the Survey Results binder and no binder was present there; Receptionist #368 stated they did not know what the Survey Results binder was or where it was located and verified there was no signage identifying its location. A later observation found the Survey Results Binder on a counter in the first floor activities room, and there was still no signage in that room identifying where the binder was located. Review of the facility handbook titled Resident's Rights and Facility Responsibilities stated the facility must post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives, and must also post notice of the availability of such reports in prominent and accessible public areas.
Failure to Implement Bowel Monitoring Policy Resulting in Fecal Impaction and Bowel Perforation
Penalty
Summary
The deficiency involves the facility’s failure to monitor and respond to a resident’s bowel status in accordance with the facility’s bowel monitoring policy and the resident’s care plan. The resident had diagnoses including Parkinson’s disease, anemia, constipation, depression, and edema, and the care plan identified a potential for constipation related to decreased mobility and medication side effects. Interventions in the care plan included monitoring and recording the frequency of bowel movements and administering laxatives per physician orders. The physician had ordered daily polyethylene glycol (Miralax) for constipation. Review of the bowel tracking report showed that the resident had a small bowel movement on one documented date, followed by no recorded bowel movements for five consecutive days. The facility’s bowel monitoring policy required the charge nurse to review the electronic medical record for residents without a bowel movement for three consecutive days and to administer PRN laxatives or other interventions such as prune juice and/or notify a clinician. The DON confirmed that the electronic medical record dashboard was designed to alert nurses when a resident had not had a bowel movement for three days, and that there was no documentation that the bowel monitoring policy was implemented after the resident went multiple days without a bowel movement. The DON also verified that the charting reflected no bowel movement for the five-day period. During this period without documented bowel movements, the resident’s condition changed. On one evening, the resident reported a pain score of five on a zero to ten scale. Later that night, a nursing note documented complaints of abdominal pain with pain upon palpation, coughing up mucus, and labored breathing. The on-call MD was notified and ordered that the resident be sent to the emergency department for evaluation and treatment, with the note indicating concern about possible delay of treatment due to a holiday. An SBAR form and progress note documented that the resident’s last bowel movement had been five days earlier. At the hospital, imaging (CTA) showed a large amount of stool in the rectum and sigmoid colon with wall thickening, mesenteric induration, and a moderate amount of pneumoperitoneum consistent with bowel perforation, likely related to fecal impaction and stercoral colitis. The resident was admitted to the hospital and subsequently died; the death certificate listed cardiac respiratory arrest as the cause of death. The MD and NP later stated they had not been notified when the resident had gone three days without a bowel movement, despite the expectation that they would be called at that point so new orders could be given. The surveyors determined that this failure to monitor and act on the resident’s bowel status according to the facility’s bowel monitoring policy and the resident’s care plan resulted in a fecal impaction with a perforated bowel requiring hospitalization and contributed to Immediate Jeopardy. The Immediate Jeopardy was cited for one resident reviewed for change of condition out of a facility census of 123 residents. The deficiency was investigated under a specific complaint number and was supported by medical record review, hospital records, staff and provider interviews, policy review, and reference to clinical information from the National Library of Medicine regarding stercoral colitis and constipation.
Removal Plan
- DON reviewed all current residents with any new progress notes to identify possible changes of condition; no concerns identified.
- Held a QA meeting with Administrator, Medical Director, DON, ADON, Corporate Nurse Educator, Regional Director of Operations, and VP of Nursing to review findings and develop, review, and approve the plan of action.
- Provided in-service education to DON and ADON by the Corporate Nurse Educator on the Change in Condition Policy and conducting assessments.
- Initiated and completed an audit of each resident with no bowel movement for three days; residents were assessed, providers contacted as appropriate, and interventions implemented as needed; bowel monitoring policy implemented for identified residents.
- Conducted in-service education for all current licensed nurses on timely assessment for potential change in condition, reviewing the EMR clinical dashboard, and related expectations; off-site nurses educated by telephone; nurses not yet educated were restricted from working until education completed.
- QA Nurse initiated an audit to ensure appropriate care plan interventions are in place and being implemented as needed; audit completed.
- Implemented review of current residents’ progress notes by DON, ADON, and unit managers to identify possible changes of condition, including residents at risk for constipation.
- Implemented ongoing review by DON, ADON, and unit managers of residents with no bowel movement noted for three days to ensure assessment, intervention, and physician notification as appropriate.
- Implemented a Performance Improvement audit worksheet for residents to ensure assessment for potential change in condition related to no bowel movement in three days, with a monitoring schedule and reporting of results to the QA committee for determination of further monitoring needs.
- Held a follow-up QA meeting with Administrator, Medical Director, DON, ADON, Regional QA Nurse, Regional Director of Operations, and VP of Nursing to review education, audit findings, and the ongoing audit schedule; QA committee to monitor.
Failure to Report Allegation of Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the state survey agency as required by its abuse policy. A cognitively intact resident with diagnoses including psychosis, hallucinations, Parkinson's disease, and neurocognitive disorder with Lewy bodies was admitted on 10/28/25. During a level two PASRR assessment, the resident stated that someone had grabbed his penis. The social worker confirmed that the administrator was notified of this allegation. The administrator later documented in a written witness statement that the resident reported someone had grabbed his penis. After speaking with the resident’s son, the administrator determined that the allegation was likely a hallucination and decided not to investigate further. No Self-Reported Incident (SRI) was initiated, and there was no report of the allegation to the state survey agency between 10/01/25 and 01/05/25. The DON verified that the administrator had been notified of the allegation. Review of the facility’s Abuse/Neglect/Misappropriation of Property policy dated September 2022 showed that any allegation of abuse or serious bodily injury must be reported to the state survey agency immediately, but no later than two hours after the allegation is made. The administrator verified that the facility did not follow its abuse policy once the allegation of sexual abuse was discovered.
Failure to Investigate and Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of sexual abuse involving Resident #14. Resident #14 was admitted with diagnoses including psychosis, hallucinations, Parkinson's disease, and neurocognitive disorder with Lewy bodies, but was documented as cognitively intact on a recent MDS assessment. During a level two PASRR assessment, the resident stated that someone had grabbed his penis. The Social Worker confirmed that the Administrator was notified of this allegation, and the DON also verified that the Administrator had been informed. The Administrator’s written witness statement documented that Resident #14 reported someone had grabbed his penis. The Administrator then spoke with the resident’s son, concluded the allegation was likely a hallucination, and decided not to investigate further. No SRI was initiated, and review of the facility’s SRI logs showed no reports of sexual abuse related to this resident during the review period. The Administrator acknowledged that the facility did not follow its Abuse/Neglect/Misappropriation of Property policy, which requires that any allegation of abuse or serious bodily injury be reported to the State Survey Agency immediately, but no later than two hours after the allegation is made.
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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 Harrison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrison Trail Health Campus | 2.4 mi | ★★★★★ | 3 | 0 |
| Three Rivers Healthcare Center | 6.2 mi | ★★★★★ | 2 | 0 |
| Liberty Nursing Center Of Colerain Inc | 8.7 mi | ★★★★★ | 8 | 0 |
| Shady Nook Care Center | 9.8 mi | ★★★★★ | 14 | 0 |
| Home At Taylor's Pointe | 9.9 mi | ★★★★★ | 0 | 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.