Shady Lawn Nursing and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF880Nov 17, 2021

  Based on observation, interview, and record review, it was determined the facility failed to ensure staff properly utilized personal protective equipment (PPE), which included the donning (putting PPE on) and doffing (taking PPE off) when entering one (1) of two (2) sampled isolation rooms. This had the potential to affect all facility residents. The findings include: Review of the Centers of Disease Control and Prevention (CDC) publication, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/ , revealed it provided guidance for the proper use of Personal Protective Equipment (PPE). […]

• No harm, potential for more than minimal, isolatedF580Aug 28, 2026

  Based on interview, and facility policy review, the facility failed to immediately notify a resident's representative of a decision to transfer/discharge the resident from the facility for 1 of 4 residents (Resident (R) 28) reviewed for transfer/discharge from the facility, out of the total sample of 12 residents. On 08/16/2026, the facility transferred R28 to a local hospital for a higher level of care; however, did not notify the resident's Power of Attorney (POA) of the transfer.The findings include:Review of the facility policy titled, Admission, Transfer, and Discharge Standard of Practice, revised 04/2025, revealed the purpose of the policy was to ensure the process of admission, discharge, and transfer met regulatory requirements. […]

• No harm, potential for more than minimal, isolatedF689Sep 8, 2022

  Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of ten (10) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #1). The facility assessed and care planned Resident #1 to require the use of a mechanical lift for all transfers. On 07/13/2022, Resident #1 sustained a fall from a mechanical lift while being transferred from the bed to the wheelchair, after staff tried to manually transfer the resident when the lift failed to operate properly. The resident was transferred to the Hospital emergency room (ER) immediately after the fall with no acute findings noted. […]

• No harm, potential for more than minimal, isolatedF908Sep 8, 2022

  Based on interview, record review, review of facility policy, and review of the facility investigation, it was determined the facility failed to ensure a mechanical lift was maintained in safe operating condition prior to use for one (1) of ten (10) sampled residents (Resident #1). On 07/13/2022, Resident #1 sustained a fall from a Bariatric Electric Patient Lift, while being transferred from the bed to the wheelchair. The lift malfunctioned, not allowing the resident to be elevated into his/her wheelchair. As a result, staff attempted to manually transfer the resident, causing the resident to slide out of the sling and onto the floor. The resident was transferred to the Hospital emergency room (ER) with no acute findings noted according to the Emergency Department (ED) note. […]