Shady Knoll Center for Health & Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF851Jun 30, 2025

  Based on review of facility documentation and staff interview, the facility failed to ensure the 1st quarter Payroll Based Journal (PBJ) report was submitted. The findings include:Review of the [NAME] 1st Quarter (10/1/24 through 12/31/24) PBJ Staffing Data Report identified there were no submittals for Registered Nurse hours and for licensed nursing coverage 24 hrs./day for 10/1/24 through 10/10/24.An interview with the Administrator on 6/30/25 at 9:43 AM and 6/30/25 at 2:30 PM identified the former owners of the facility were responsible for nursing staff PBJ submissions and failed to complete transmissions 10/1/24 through 10/10/24 as an oversight before the change of ownership which was effective 10/10/24.Although a policy for PBJ submission was requested, none was provided.

• No harm, potential for more than minimal, patternF686Jun 30, 2025

  Based on review of the clinical record, staff interviews, facility documentation, and facility policy for 1 of 3 residents (Resident #31) reviewed for pressure ulcers, the facility failed to follow physician orders timely and initiate treatment orders for a newly identified wound. The findings include:Resident #31's diagnoses included unspecified dementia, chronic kidney disease, and essential hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was severely cognitively impaired and dependent on staff for shower/bathing, lower body dressing, and putting on/taking off footwear.Review of a skin condition binder located on the 3rd floor identified on 4/28/25 a new skin issue/concern for Resident #31 was identified on the 3:00 PM to 11:00 PM shift… […]

• No harm, potential for more than minimal, patternF756Jun 30, 2025

  Based on clinical record review, facility documentation, facility policy and staff interviews for 1 of 5 residents (Resident #93) reviewed for unnecessary medications, the facility failed to review and respond to pharmacy recommendations in a timely manner. The findings include:Resident #93 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety, and hypertension.A physician's order dated 12/10/24 directed to administer Citalopram Hydrobromide (Celexa) (an antidepressant medication) 40 milligrams(mg) 1 tablet by mouth once a day.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #93 was severely cognitively impaired, dependent on bathing, dressing, and toileting. […]

• No harm, potential for more than minimal, patternF804Jun 30, 2025

  Based on a temperature meal tray sample taken with the Dietary Director and staff/resident interviews, the facility failed to ensure meals was served at appropriate temperatures.During the Resident Council meeting on 6/24/25 at 1:34 PM, residents complained of ongoing issues with food being served cold. On 6/25/25 at 12:35 PM, a test tray was conducted. The following was identified:The lunch meal was plated and left the Dietary Department on a variety of serving carts which were two tiered and open to air starting at 11:45 AM which were filled with 7 to 8 meals on each serving cart, plated and covered with a clear plastic lid with a hole in the center. […]

• No harm, potential for more than minimal, patternF812Jun 30, 2025

  Based on the tour of the Dietary Department, staff interviews, and review of facility policies, the facility failed to ensure opened items were labeled and dated when opened, and expired food was discarded. The findings include:Tour of the Dietary Department on 6/23/25 at 9:55 AM during the initial walk through with the Dietary Director identified the following:a. A large bag of Ciabatta Garlic bread sticks opened, not dated, located in the walk-in freezer.b. 4 (gallon sized) opened freezer bags of frozen chicken wings observed in the walk-in- freezer were not dated when opened.c. 1 (1 pound) bag of coconut half full, not dated and open to air located in the dry storage room.d. […]