Shady Acres Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Shady Acres Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Oct 23, 2025

  Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure Resident #1, and Resident #6 were free from sexual abuse when Resident #6 was observed in the secure unit TV room with her hand down Resident #1's pants and Resident #1 was holding Resident #6's hand and arm and would not allow it to be removed. Nursing staff had to manually remove Resident #6's hand from Resident #1's penis and Resident #1 became angry on 03/12/2025. 2. […]

• Immediate jeopardy, patternF609Oct 23, 2025

  Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. […]

• Immediate jeopardy, patternF656Oct 23, 2025

  Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 10 residents (Resident's #1, #2, #3, #4, #5, #7, and #8) reviewed for care plans. 1. The facility failed to develop, revise and implement interventions in Resident #1's care plan on 03/12/2025, 07/01/2025 and 08/20/2025 to include interventions to prevent sexual abuse of other residents. 2. […]

• Immediate jeopardy, isolatedF600Dec 11, 2025

  Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from sexual abuse for two of six residents (Residents #2 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #2 was free from sexual abuse when Resident #1 came into Resident #2's room on 11/02/2025 and inappropriately touched her breast and genital area. 2. The facility failed to ensure Resident #3 was free from sexual abuse when Resident #3 reported to facility staff on 11/04/2025 on an unidentified date Resident #1 touched her breast without consent. The noncompliance was identified as a past non-compliance (PNC) Immediate Jeopardy. The Immediate Jeopardy (IJ) began on 11/02/2025 and ended on 11/05/2025. […]

• Immediate jeopardy, isolatedF689Jul 26, 2024

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 of 14 residents (Resident #s 1, 2 and 3) reviewed for smoking. 1. The facility failed to ensure Residents #2 and #3 were smoking safely in a designated smoking area. On 07/19/24, Resident #1, who utilized oxygen, and Residents #2 and #3 (assessed as smokers) were in a nonsmoking area. Resident #1's oxygen caught on fire, and she sustained multiple burns to her face, chest, and hands. 2. The facility failed to ensure Resident #2 and Resident #3 did not keep their smoking materials in their room. 3. The facility failed to ensure Residents #2 and #3 were re-assessed for smoking safety. On 07/24/24 at 12:26 p.m. […]