Shady Lawn Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 12, 2025

  Based on closed medical record review, hospital record review, death certificate review, investigation review, drug information review, interview and policy review the facility failed to ensure staff belongings were properly secured to prevent access to Resident #11 and failed to ensure a condition change was timely reported to medical practitioners resulting in resident neglect. This resulted in Immediate Jeopardy and Actual Harm/subsequent death on [DATE] between 5:00 A.M. and 6:00 A.M. when Resident #11, who resided on a secured behavior unit and had a history of drug use and drug seeking behavior, accessed Certified Nurse Assistant (CNA) #120's purse (which was located at an unsecured nursing station) and obtained the prescription medication, Adipex (a stimulant). […]

• Actual harm, isolatedF684May 12, 2025

  Based on closed medical record review, policy review and interview, the facility failed to timely identify and obtain medical intervention for Resident #77 following an acute change in condition. Actual harm occurred when the facility failed to provide timely intervention for Resident #77 following an acute change in condition. On 02/20/25 Resident #77, who had a physician order for comfort measures in the event of cardiac or respiratory arrest, was noted to have emesis, decreased fluid intake and adventitious lung sounds with no evidence the physician or family were notified or effective interventions initiated. On 02/21/25 at 1:07 A.M. […]

• Actual harm, isolatedF686May 12, 2025

  Based on observation, record review, interview, and policy review, the facility failed to develop and implement a comprehensive, effective and individualized resident centered pressure ulcer prevention and treatment program for Resident #46, Resident #48 and Resident #58 to prevent the development of pressure ulcers, to ensure treatments were completed as ordered and to promote timely and optimal healing of pressure ulcers. Actual Harm occurred on 05/06/25 when Resident #48, who was dependent on staff for bed mobility and toileting, and always incontinent of bowel and bladder, was assessed to have a dark purple, non-blanchable suspected deep tissue injury pressure ulcer (a localized area of discolored, intact skin or a blood-filled blister, often purple or maroon, due to damage of… […]

• No harm, potential for more than minimal, widespreadF812May 12, 2025

  Based on observation, interview and review of the facility policy, the facility failed to ensure foods were appropriately stored and discarded when expired. This had the potential to affect 76 residents in the facility receiving food from the kitchen (Resident #40 was ordered nothing by mouth). Facility census was 77. Findings include: Observation on 04/28/25 from 8:36 A.M. to 9:12 A.M. with Dietary Manager (DM) #517 revealed in the walk-in cooler, there was a sheet pan with foil loosely placed over it exposing the contents to air. Beneath the foil was a cut of meat and writing on the foil identified the meat as pork and provided a date of 04/25/25. Continued observation of the walk-in cooler revealed four expired bags of carrots with dates of 02/10/25 or 03/13/25. […]

• No harm, potential for more than minimal, widespreadF835May 12, 2025

  Based on observation, record review, job description review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 77 residents residing in the facility. Findings include: During the annual, complaint and extended survey, observations, record reviews, interviews, policy and facility assessment review resulted in concerns including but not limited to situations of neglect resulting in Immediate Jeopardy and actual harm to residents. […]