Shady Nook Care Center

In the surveyor’s words

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

• Actual harm, isolatedF760Nov 20, 2025

  Based on record review and interview, the facility failed to ensure a resident was free from a significant medication error when Resident C received Resident L's morning medications. The deficient practice resulted in the resident's hospitalization, administrations of two doses of Narcan, monitoring of vitals, and laboratory values for 1 of 3 residents reviewed for medication errors. (Resident C) Findings include:The resident's clinical record was reviewed on 11/20/2025 at 10:13 A.M. A Quarterly Minimum Data Set assessment, dated 08/27/25, indicated the resident was severely cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF812Nov 13, 2024

  Based on observation, interview, and record review, the facility failed to prepare and store foods in a sanitary manner for 2 of 2 kitchen observations and failed to maintain resident snack refrigerators in a sanitary manner related to the storage of non-food items and outdate foods for 3 of 3 snack refrigerators observed. This deficient practice had the potential to affect on 82 of 82 residents who receive food from the kitchen or snack refrigerators. Findings include: 1. During the initial kitchen tour on 11/06/24 at 11:14 A.M., with the Dietary Manager (DM), the following was observed: - The dry storage room floor was littered with pieces of dry cereal, a package of crackers; a line of white powder, one and a half inches wide by two feet long running along the wall behind a wire rack… […]

• No harm, potential for more than minimal, patternF755May 11, 2023

  Based on interview and record review, the facility failed to administer medications in a timely manner for 5 of 5 residents reviewed for medications. (Residents B, C, D, E, and F) Findings include: 1. The record for Resident B was reviewed on 5/10/23 at 11:00 a.m. The diagnoses included, but were not limited to, neoplasm of unspecified behavior of brain, hypertension, and bipolar disorder. A Medication Administration Audit Report for the physician ordered medications for Resident B was provided by the DON (Director of Nursing) on 5/11/23 at 12:00 p.m. The report indicated the resident's medications were given late on the following dates and times: - On 4/6/23 the medications were due at 7:00 p.m. and were given at 9:10 p.m., - On 4/8/23 the medications were due at 7:00 p.m. […]

• No harm, potential for more than minimal, patternF812Aug 4, 2022

  Based on observation and interview, the facility failed to store foods in a sanitary manner related to unlabeled (chicken soup and tenders) and outdated (milk cartons, mozzarella cheese) foods during 1 of 3 kitchen observations. Findings include: During the initial tour of the kitchen with the Kitchen Manager on [DATE] at 2:25 P.M., the following was observed: The large, walk-in refrigerator contained the following items: - 5 single serving cartons of fat free skim milk with an expired on date of [DATE]. - A gallon sized container ,d+[DATE] filled with mozzarella cheese, with a prepared on label dated [DATE]. The Kitchen Manager indicated the expired milk should have been discarded. The cheese was good for 5 to 7 days after it was opened, and it should be discarded. […]

• No harm, potential for more than minimal, isolatedF842May 12, 2026

  Based on record review and interview, the facility failed to ensure accurate documentation was completed related to a resident's pain medication for 1 of 3 residents reviewed for accuracy of records. (Resident B) Findings include:The clinical record for Resident B was reviewed on 05/12/2026 at 9:14 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/19/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, cancer (the uncontrolled growth and spread of abnormal cells in the body), chronic kidney disease (an illness were the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and end-stage renal failure (severe kidney failure where kidney function is less than 15% of normal). […]