Shady Lane Nursing Care Center

In the surveyor’s words

From the most serious findings on record at Shady Lane Nursing Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 24, 2026

  Based on interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 resident (R) (R52) of 4 sampled residents. When staff lowered R52's bed on 4/28/26, the bed became caught on a radiator below the windowsill which caused the bed to tilt at an angle. The positioning of the bed was not reported to administration or addressed in R52's care plan. The following day, R52 fell out of bed and sustained a skin tear on the right forearm that required 6 sutures. R52's bed was caught on the radiator and tilted at a 30 degree angle at the time of the fall. […]

• Actual harm, isolatedF880Apr 16, 2025

  Based on observation, staff and resident representative interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 1 resident (R) (R14) of 1 resident who used a humidifier and contracted Legionnaires' disease. The facility also did not ensure COVID-19 positive staff members returned to work in accordance with the facility's policy. In addition, the facility did not ensure enhanced barrier precautions (EBP) were implemented for 1 resident (R25) of 2 sampled residents. R14 used a humidifier that was filled with tap water and was diagnosed with Legionnaires' disease on 3/4/25. […]

• Actual harm, isolatedF686Dec 15, 2021

  Based on observation, record review, and staff interviews, the facility did not ensure 1 Resident (R) (R36) of 2 residents reviewed for pressure injuries received appropriate care and services to promote healing. R36's medical record included documentation that R36 was at risk for pressure injuries and had a current re-opened Stage 4 pressure injury to the coccyx that was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's medical record indicated that R36 developed a stage IV pressure injury (indicating full thickness tissue loss and palpable bone) on 5/30/19 and that it had healed as of November of 2020. […]

• No harm, potential for more than minimal, patternF689Dec 15, 2021

  Based on observation, interview, and record review, the facility did not ensure supervision and assistance to prevent accidents was provided to each Resident (R) for 4 (R32, R28, R92, and R12) of 12 sampled residents. Staff did not ensure R32's [MEDICATION(S)] (bronchodilator) inhaler was secured when R32 was not present. The facility did not assess R12 for safety to self-administer nasal saline spray. Surveyor observed R12 nasal saline spray on bedside table. R12 confirmed to Surveyor independent use of nasal saline spray. R28 was observed to have 1 pill on R28's bedside table. R28 was not in R28's room. R92 was observed to be putting in Refresh Eye Drops into R92's eyes when Surveyor entered R92's room. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF689Apr 16, 2025

  Based on staff interview and record review, the facility did not ensure a timely fall intervention was implemented for 1 resident (R) (R32) of 1 sampled resident. R32 fell on [DATE]. The facility did not implement timely and appropriate fall interventions before R32 fell again on 9/9/24 and 11/12/24. Findings include: The facility's Falls I&A policy, revised 6/2016, indicates: The Interdisciplinary falls team is key to addressing the issue of resident falls which shall be responsive to assuring resident safety within the limits of practicability .The facility is committed to minimizing resident falls so as to maximize each resident's mental and psychosocial well-being .It is the facility's policy to act in a proactive manner to identify and assist those residents at potential for risk for… […]