Shadelands Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 74) to prevent falls and injuries when Resident 74 with history of unwitnessed falls was found sitting by the foot of her bed with gushing of blood from forehead and two open skin tears. This failure caused Resident 74 to continue to fall and had the potential to result in severe injuries. During a review of Resident 74's admission Record (AR), printed on 5/14/26, AR indicated Resident 74 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait and mobility (ability to move, walk or change position easily and freely), hemiplegia and hemiparesis affecting left side (stroke), lack of coordination, cognitive communication deficit. [...]

Inspectors wroteBased an observation, interview and record review, the facility failed to observe infection control practices when residents dirty clothing were not bagged properly when transported to the laundry. This failure had the potential for spread of infections among residents at the facility. During a concurrent observation and interview on 5/13/26 at 3:19 p.m. with Environmental Services Director (ES), three mesh bags of residents dirty clothing were observed on the floor in the laundry room. ES stated resident's dirty clothing should be covered with a plastic bag when transported to the laundry room to prevent spread of infection. During an interview on 5/14/26 at 9:18 a.m. with Certified Nursing Assistant (CNA3), CNA 3 stated that residents dirty clothing are place in a plastic bag then hamper when transported to the laundry. During an interview on 5/14/26 at 10:45 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the implementation of its antibiotic use protocols for one of nine sampled residents (Resident 25), that address unnecessary or inappropriate antibiotic use. This failure had the potential for residents to receive unnecessary antibiotics and risk of development of antibiotic-resistant organisms. During a review of Resident 25's Nurse's Note (NN), dated 4/11/26, The NN indicated Resident 25's daughter stated Resident 25's had frequent urination throughout the night. Resident 25's daughter called the facility and spoke with supervisor. MD was notified of Resident 25's symptoms and Urine test /Culture & Sensitivity (UA/C/S) was ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four of nine sampled residents (Residents 3, 9, 24) were offered appropriate pneumococcal (PNA- a disease that can cause infection in the lung) vaccination series. This failure had the potential to place Residents 3, 9, 24 and 34 at risk to be infected and spread of pneumococcal infection. During a review of Resident 3's admission Record (AR), printed on 5/13/26, AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia (memory loss). During a concurrent interview and record review on 5/13/2026 at 2:02 p.m. with Licensed Vocational Nurse/ Infection Preventionist (IP), Resident 3's Immunization Record (IR). was reviewed. IR indicated Resident 3 had pneumococcal PPSV23 vaccine in 10/28/16. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 74), was provided information necessary to obtain an informed consent prior to the administration of Trazodone ( an antidepressant medication used for treatment of major depressive disorder in adults), when the physician (MD1) did not inform Resident 74's responsible party (RP) in advance of the use, risks, and benefits of Trazodone. This failure had the potential to deny residents and surrogate decision maker information needed to make an informed decision. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate pain assessment was performed for one of eight sampled residents (Resident 18) when Resident 18, who was able to communicate verbally, was assessed for pain by facility staff using the Pain Assessment in Advanced Dementia (PAINAD, is an observational tool used to assess pain in patients with severe cognitive impairment who cannot verbally communicate their pain). This failure resulted in Resident 18 to receive pain medication without appropriate pain assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled medication (those with high potential for abuse and addiction) were fully accounted when random controlled medication use audit for one of three residents (Resident 1) did not reconcile. The controlled medication was signed out of the controlled drug record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate the medication was given to the resident. This failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purpose not intended by the prescriber) of controlled medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility had a 7.69% error rate when two medication errors out of 26 opportunities were observed during the medication administration for two of eight sampled residents (Residents 18 and 59) when:1. Resident 18 received tramadol (medication used to treat pain) with a pain level of zero (no pain).2. Resident 59 did not receive polyethylene glycol (an over-the-counter medication used to treat occasional constipation) as ordered. These failures resulted in Resident 18 and 59 receiving medication not in accordance with the prescriber's orders.1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper medication storage and labeling practices when:1. An afrin nasal spray (an over-the-counter medication that provides relief for nasal and sinus congestion) was unlabeled with Resident 60's name during medication administration observation.2. Resident 60's alvesco inhaler (medication used for the maintenance treatment of asthma) was stored in the medication cart without prescriber's order during the inspection of one of two sampled medication cart. These failures had the potential to result in unsafe medication administration and storage practices.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position, when facility's dietary manager was also not qualified/certified. This failure had the potential for lack of competency and skill set necessary to carry out all the functions of the food services. During an interview on 5/11/26 at 2:46 p.m. with Dietary Manager (DM), DM stated that he was not a certified dietary manager. DM stated he was currently in school. During an interview on 5/11/26 at 3:06 p.m. with Registered Dietician (RD), RD stated that she was hired to work on part time. RD stated she worked 24 hours a week. During an interview on 5/13/2026 at 1:02 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a binding arbitration agreement (a contract in which parties agree to resolve disputes outside of court) was explained in a manner that was understandable to one of three sampled residents (Resident 25's) family representative (FR 1). This failure had the potential to prevent FR 1 from making an informed decision regarding whether to enter into a binding arbitration agreement. During a review of Resident 25's admission Record, printed 5/14/26, the Record indicated Resident 25 was admitted to the facility in March 2026 with a diagnosis of major depressive disorder. During an interview on 5/13/26, at10:45 a.m., with FR 1, FR 1 stated they completed Resident 25's admission paperwork and signed their binding arbitration agreement. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the essential equipment were properly maintained when; Resident 34's bed made loud cranking noise when bed was moved up and down during care. This failure had the potential to cause residents distress or discomfort. During a concurrent observation and interview on 5/12/26 at 10:03 a.m. with Certified Nursing Assistant (CNA 1) and Licensed Vocational Nurse (LVN1), Resident 34's healed wound on buttock was observed. Resident 34's bed made loud cranking noise when remote was operated to bring the bed up and down. Resident 34 stated he can live with the noise. During an interview on 5/12/26 at 10:06 a.m. with CNA 1, CNA 1 stated Resident 34's bed makes loud noise from time to time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified staff for facilily with census of 59 residents. This failure resulted in all residents receiving social services from unqualified staff. During an interview on 3/16/26, at 3:36 p.m., with Social Services Director (SSD), SSD stated they had worked here since 2022. During a concurrent interview and record review on 3/17/26, at 12:17 p.m., with Human Resources (HR), SSD's two job descriptions titled Job Description: Social Services Director, dated 9/8/23 and 9/2/25, was reviewed. HR stated the newer job description was changed to have the entire qualifications section which included education, the ability to read and solve practical problem be preferred qualities. [...]

Inspectors wroteBased on observation, interview and review, the facility failed to ensure, for Residents 1-5, the scheduled (controlled medication, narcotic) medication system was accurate (information matches between documents). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were inaccurate. These failures resulted in the potential for the undetected loss and diversion of scheduled medications. In addition, these failures resulted in the potential for avoidable medication errors (medication not given as ordered). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and secure order communication among providers when medication order was communicated via a group messaging system involving nursing staff's personal smart phone (a mobile phone that performs many of the functions of a computer, typically having a touchscreen and internet access) for one resident out of 15 sampled residents (Resident 166) based on regulatory requirements on Protected Health Information (or PHI, any information in the medical record that can be used to identify an individual in the course of providing a health care services) This failure could violate residents' health information privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and accountable pharmaceutical services based on standards of practice and regulatory requirements with census of 59 when: 1. The prescription medication delivery or shipping manifest and receipts (a document generated by pharmacy containing shipment information on drugs delivered to the facility), including narcotic opioid (drugs with risk of abuse) medications, were not consistently signed, and acknowledged by licensed staff upon delivery for accountability. 2. The non-narcotic prescription medication destruction and disposals were not co-signed by two licensed staff on all the documented records. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nurses followed proper infection control precautions to prevent spread of infection for five of eight sampled residents (Resident 166, Resident 158, Resident 15, Resident 43, and Resident 6) when the medication tray was not cleaned and sanitized after taking the tray was placed on Resident 158's bedside table in Resident 158's room, and then placed on the bedside tables of Resident 43, Resident 15, and Resident 166. These deficient practices had the potential to result in the spread of infection at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure psychotropic (mind altering drugs) medications were properly assessed for use with a documented diagnosis by the medical doctor in the medical record in one out of five residents reviewed for unnecessary medications (Resident 33). This failed practice could contribute to unsafe medication use, monitoring, and adverse consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage and labeling practices with census of 59 when: 1. Unlabeled prescription medication was stored in medication room at Unit 1. 2. Non-refrigerated medication was stored in the medication refrigerator at Unit 1. 3. The inhalation medication with limited shelf life after opening was not dated for beyond use date in medication cart #3. 4. Treatment cart stored opened and used wound care supplies marked for single use in the active storage area. These failed practices could contribute to unsafe used of medication and supplies.

Inspectors wroteBased on interview and record review, for two of three sampled residents (Resident 1 and Resident 2), the facility: -Failed to provide Resident 1 and Resident 2 a notice of proposed discharge within the required timeframe of at least 30 days prior to the actual discharge day. - Failed to send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. These failures had the potential to result in the lack of added protection to Resident 1 and Resident 2 from being inappropriately discharged , without access to an advocate who can inform them of their options and rights.

Inspectors wroteBased on interview and record review, for three of three sampled residents (Resident 1, Resident 2, and Resident 3), the facility failed to provide a summary of the Baseline Care Plan. This failure had the potential to result in the lack of information about Resident 1, 2 and 3's goals of care and discharge plan.