Shady Grove Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Shady Grove Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 16, 2025

  Based on observation, interview, record review, facility policy review, and review of manufacturer's guidelines for mechanical lifts and for mechanical lift slings, the facility failed to follow the guidelines for operation of the mechanical lift for 1 (Resident #2) of 2 residents observed that were transferred with a sling. The failure to follow the facility policy and guidelines supplied by the manufacturer contributed to Resident #2 sustaining a severely comminuted (a fracture of a bone into three or more pieces usually from high impact trauma or a fall from heights) fracture. Findings included: A facility policy titled, Mechanical Lift, dated 01/29/2024, revealed the section titled, Procedure, included, 2. Two trained staff must assist with mechanical lift and transfer. […]

• No harm, potential for more than minimal, widespreadF657Mar 13, 2025

  Based on record review and interview with staff it was determined that the facility staff failed to: 1) ensure the resident's person-centered care plan was reviewed and revised in response to current interventions to meet the respiratory needs and 2) failed to ensure residents were offered the opportunity to participate in the care planning process by holding annual and quarterly care plan meetings. This was evident for 9 (#25, #38, #42, #49, #52, #54, #74, #82, & #95) out of 10 residents records reviewed for care planning during the recertification survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. […]

• No harm, potential for more than minimal, widespreadF726Jan 15, 2021

  Based on surveyor observation and facility staff interview it was determined that the facility failed to ensure nursing staff had the competency and skills to provide care to meet residents' needs. This finding was evident on all units. The findings include: 1. On 01-13-2021 at 1:28 PM, surveyor observed GNA #6 passing lunch trays. She picked up a tray and entered room [ROOM NUMBER]. She placed the tray on the bedside table. She assisted a resident with personal belongings, then set up the resident's food tray. GNA #6 did not have gloves on. She then left room [ROOM NUMBER] without performing hand hygiene. With her bare hands, she picked up another tray from the food cart in the hallway and entered room [ROOM NUMBER]. […]

• No harm, potential for more than minimal, patternF684Jun 15, 2026

  Based on reviews of a closed clinical record, all pertinent facility administrative records, and interviews with the facility staff, it was determined that the facility nursing staff failed to 1) follow the physician's specific pulse and blood pressure parameters before administering cardiac medications to residents, and 2) failed to document an associated blood pressure before administering the cardiac medication. This was evident for 1 (Resident #1) of 4 residents reviewed during a complaint survey. The findings include: A) A review of Resident #1's closed clinical record on 06/12/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation, hypertension, hypotension, and end stage renal disease. […]

• No harm, potential for more than minimal, patternF812May 8, 2026

  Based on observations and interviews, it was determined that the facility failed to maintain food storage and food service equipment in a safe and sanitary manner to help prevent potential foodborne illness. This deficient practice was evident for 1 of 1 resident food storage refrigerator reviewed, and during the kitchen tour conducted during the annual survey. The findings include1. On 5/4/2026 at 8:10 AM, the surveyor observed a refrigerator in a dining area on the Ambassador unit. Dried tan and red spills covered one-third of the refrigerator's bottom, which also contained crumbs. […]