Shadelands Post Acute

In the surveyor’s words

From the most serious findings on record at Shadelands Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF836May 7, 2026

  Based on observation, interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified staff for facilily with census of 59 residents.This failure resulted in all residents receiving social services from unqualified staff.During an interview on 3/16/26, at 3:36 p.m., with Social Services Director (SSD), SSD stated they had worked here since 2022.During a concurrent interview and record review on 3/17/26, at 12:17 p.m., with Human Resources (HR), SSD's two job descriptions titled Job Description: Social Services Director, dated 9/8/23 and 9/2/25, was reviewed. […]

• No harm, potential for more than minimal, patternF689May 14, 2026

  Based on interview and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 74) to prevent falls and injuries when Resident 74 with history of unwitnessed falls was found sitting by the foot of her bed with gushing of blood from forehead and two open skin tears.This failure caused Resident 74 to continue to fall and had the potential to result in severe injuries. During a review of Resident 74's admission Record (AR), printed on 5/14/26, AR indicated Resident 74 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait and mobility (ability to move, walk or change position easily and freely), hemiplegia and hemiparesis affecting left side (stroke), lack of coordination, cognitive… […]

• No harm, potential for more than minimal, patternF880May 14, 2026

  Based an observation, interview and record review, the facility failed to observe infection control practices when residents dirty clothing were not bagged properly when transported to the laundry.This failure had the potential for spread of infections among residents at the facility. During a concurrent observation and interview on 5/13/26 at 3:19 p.m. with Environmental Services Director (ES), three mesh bags of residents dirty clothing were observed on the floor in the laundry room. ES stated resident's dirty clothing should be covered with a plastic bag when transported to the laundry room to prevent spread of infection.During an interview on 5/14/26 at 9:18 a.m. […]

• No harm, potential for more than minimal, patternF881May 14, 2026

  Based on interview and record review the facility failed to ensure the implementation of its antibiotic use protocols for one of nine sampled residents (Resident 25), that address unnecessary or inappropriate antibiotic use.This failure had the potential for residents to receive unnecessary antibiotics and risk of development of antibiotic-resistant organisms. During a review of Resident 25's Nurse's Note (NN), dated 4/11/26, The NN indicated Resident 25's daughter stated Resident 25's had frequent urination throughout the night. Resident 25's daughter called the facility and spoke with supervisor. […]

• No harm, potential for more than minimal, patternF883May 14, 2026

  Based on interview and record review, the facility failed to ensure four of nine sampled residents (Residents 3, 9, 24) were offered appropriate pneumococcal (PNA- a disease that can cause infection in the lung) vaccination series.This failure had the potential to place Residents 3, 9, 24 and 34 at risk to be infected and spread of pneumococcal infection.During a review of Resident 3's admission Record (AR), printed on 5/13/26, AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia (memory loss). During a concurrent interview and record review on 5/13/2026 at 2:02 p.m. with Licensed Vocational Nurse/ Infection Preventionist (IP), Resident 3's Immunization Record (IR). was reviewed. […]