Shady Oak Nursing and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF570Jul 14, 2023

  Based on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 facility review for the surety bond, in that: The facility's surety bond was not enough to match the total residents' trust fund account balance. This failure could place residents who deposit personal funds with the facility at-risk of their personal funds not being assured. […]

• No harm, potential for more than minimal, patternF880Sep 5, 2025

  Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 5 residents (Residents #4, #7 and #21) reviewed for infection control, in that: 1. The facility failed to maintain correct infection control when, while providing wound care for Resident #4, LVN C failed to use proper protective equipement. 2. The facility failed to maintain correct infection control when, while observing Resident #7's room, a reusable urinal was seen hang uncovered and hanging from the resident's trash can. 3. […]

• No harm, potential for more than minimal, patternF921Aug 8, 2024

  Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 shower rooms reviewed, in that: 1. The South Hall shower room had a strong foul odor. 2. The temperature in the facility kitchen was 95.1 degrees Fahrenheit. These deficient practices could place residents at risk and result in an environment that is not safe, functional, sanitary, or comfortable for residents, staff, and visitors. The findings were: Observation on 08/05/2024 at 10:42 a.m. revealed a strong foul odor was emanating from the shower room in the South Hall. […]

• No harm, potential for more than minimal, patternF607Jul 14, 2023

  Based on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 10 of 18 staff (The DS, AD, MA A, CNA D, CNA E, MA F, Cook G, LVN I, RN J, and MDS Coordinator) reviewed for employment registry screenings, in that: The DS, AD, MA A, CNA D, CNA E, MA F, Cook G, LVN I, RN J, and MDS Coordinator did not have current employment registry screenings. […]

• No harm, potential for more than minimal, patternF944Jul 14, 2023

  Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk for injury or improper care due to a lack of training. […]