Shady Acres Health & Rehabilitation

Inspectors wroteBased on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and designate a RN as a DON on a full-time basis for 1 of 1 facility reviewed for nursing services. The facility failed to ensure an RN worked for 8 consecutive hours for 20 of 116 days reviewed in January, February, March and April 2026. The facility failed to designate an RN as a DON on a full-time basis for 30 of 87 days reviewed in February, March and April 2026. This failure could place residents at risk of not having their nursing and medical needs met, and other direct care staff not receiving sufficient oversight.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety requirements. The facility failed to ensure there was no fly tape with bugs on it approximately 12 inches away from refrigerator B.The facility failed to ensure floors did not have a sticky substance. The facility failed to ensure there were no fuzzy green spots on refrigerator A's wire rack. The facility failed to ensure the ice machine was free of lime build up. The Dietary Supervisor and Dietary Aide/ [NAME] C did not have bread restraints on their beards. These failures could place residents at risk of foodborne illness, and food contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free of significant medication errors, for 1 of 14 residents reviewed for significant medication errors. (Residents #3)The facility failed to ensure staff held Resident #3's two blood pressure medications when the blood pressure was outside the prescribed parameters. This failure could place residents receiving medication to lower the blood pressure at risk for adverse consequences and decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 2 of 3 medication carts observed (Hall D and Hall C medication carts). The facility failed to ensure Hall D and Hall C medication cart drawers did not have loose pills in the bottom of the carts. These failures could place residents at risk of misappropriation of drugs, not receiving prescribed drugs or contaminated medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and 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 diseases and infections for 1 of 5 residents (Resident #5) reviewed for infection control. The facility failed to ensure CNAs E and F wore PPE when providing ADL care to Resident #5 who was on enhanced barrier precaution. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from sexual abuse for two of six residents (Residents #2 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #2 was free from sexual abuse when Resident #1 came into Resident #2's room on 11/02/2025 and inappropriately touched her breast and genital area. 2. The facility failed to ensure Resident #3 was free from sexual abuse when Resident #3 reported to facility staff on 11/04/2025 on an unidentified date Resident #1 touched her breast without consent. The noncompliance was identified as a past non-compliance (PNC) Immediate Jeopardy. The Immediate Jeopardy (IJ) began on 11/02/2025 and ended on 11/05/2025. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 3 of the 4 incidents reviewed for reporting. 1. The Administrator or designated representative failed to report the results of an investigation within 5 days to the State Survey Agency for Resident #1's allegation of inappropriately touching Resident #2 reported on 11/3/2025 and Resident #1 allegation of inappropriately touching Resident #3 reported on 11/04/2025. 2. The Administrator or designated representative failed to report the results of an investigation within 5 days to the State Survey Agency for Resident #18's allegation of injury of unknown origin on 11/30/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure Resident #1, and Resident #6 were free from sexual abuse when Resident #6 was observed in the secure unit TV room with her hand down Resident #1's pants and Resident #1 was holding Resident #6's hand and arm and would not allow it to be removed. Nursing staff had to manually remove Resident #6's hand from Resident #1's penis and Resident #1 became angry on 03/12/2025. 2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 7 of 10 residents (Resident #1, #2, #3, #4, #5, #6, and #7) reviewed for abuse. 1. The facility failed to ensure LVN H reported a verbal and physical abuse allegation immediately to the Abuse Coordinator when Resident #3 threw coffee and threatened to kill Resident #7. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 10 residents (Resident's #1, #2, #3, #4, #5, #7, and #8) reviewed for care plans. 1. The facility failed to develop, revise and implement interventions in Resident #1's care plan on 03/12/2025, 07/01/2025 and 08/20/2025 to include interventions to prevent sexual abuse of other residents. 2. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had alleged abuse allegations on 04/19/2025, 05/14/2025, 05/18/2025, 05/27/2025 and 06/11/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 of 6 residents observed for oxygen management. (Residents #1, #6, and #39) 1. The facility failed to keep the oxygen concentrator (machine that takes air from your surroundings and extract oxygen and filters the air into purified oxygen to breath) filter clean for Resident #1. 2. The facility failed to failed to keep the oxygen concentrator (machine that takes air from your surroundings and extract oxygen and filters the air into purified oxygen to breath) filter clean for Resident #6. 3. The facility failed on 02/11/2025 to apply clean filters to Resident #39's concentrator and the facility failed to clean the area manufactured to hold the filters in place. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove in the kitchen was in a safe operating condition when on 02/10/2025 one of six burners did not light when turned on. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate assessments were completed for 1 of 14 residents (Resident #5) reviewed for accuracy of assessments. The facility failed to ensure Resident #5's quarterly MDS assessment dated [DATE] was not inaccurately coded for injection and insulin use when Resident #5 had no diagnosis or order for insulin injections. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased observation, interview, and record review, the facility failed to establish and 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 diseases and infections for 1 (Resident #6) of 14 residents reviewed for Infection Control. The facility failed to ensure Resident #6 pleural (tissue that lines the chest cavity and covers the lungs) drain bag (this is a flexible tube that drains fluid from the pleural space into in a drainage bag) and the drain port was not on the floor on 02/11/2025. This failure could place residents at risk of cross-contamination and the development of infections.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 14 (Resident #1)residents reviewed for accidents/supervision. The facility failed to ensure Resident #1's fall matt was adjacent to her bed on 11/08/24. Resident #1 fell had an unwitnessed fall and sustained a 3 cm laceration above her right eye. This failure could place residents at risk of severe injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 14 residents (Resident #2) reviewed for abuse. The facility failed to ensure CNA F did not verbally abuse Resident #2 when she made intimidating remarks at the resident on 08/26/24. The noncompliance was identified as PNC. The noncompliance began on 08/26/24 and ended on 08/26/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on interviews and record review, the facility failed conduct a thorough investigation and to report the results of all investigations to the Administrator or his or her designated representative and to other official in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 5 residents (Resident #3) reviewed for reporting results of all investigations. The facility failed to investigate and submit the results of their investigation within 5 days after Resident #3's fall. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 14 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's fall risk care plan accurately addressed and included a fall mat. This failure could place residents at risk for staff not being aware of the resident needs and not receiving the care and services to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 of 14 residents (Resident #s 1, 2 and 3) reviewed for smoking. 1. The facility failed to ensure Residents #2 and #3 were smoking safely in a designated smoking area. On 07/19/24, Resident #1, who utilized oxygen, and Residents #2 and #3 (assessed as smokers) were in a nonsmoking area. Resident #1's oxygen caught on fire, and she sustained multiple burns to her face, chest, and hands. 2. The facility failed to ensure Resident #2 and Resident #3 did not keep their smoking materials in their room. 3. The facility failed to ensure Residents #2 and #3 were re-assessed for smoking safety. On 07/24/24 at 12:26 p.m. an Immediate Jeopardy (IJ) situation was identified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Federal, State, and Local laws and regulations regarding smoking, smoking areas, and smoking safety for 3 of 3 residents (Resident #s 1, 2, and 3) reviewed for smoking safety. 1. The facility failed to ensure Residents #2 and #3 were smoking safely in a designated smoking area. On 07/19/24, Resident #1, who utilized oxygen, and Residents #2 and #3 (assessed as smokers) were in a nonsmoking area. Resident #1's oxygen caught on fire, and she sustained multiple burns to her face, chest, and hands. 2. The facility failed to ensure Residents #2 and Resident #3 were supervised while they were smoking. 3. The facility failed to ensure Resident #2 and Resident #3 did not keep their smoking materials in their room. 4. The facility failed to ensure Resident #2 and #3 were re-assessed for smoking safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 3 of 6 residents (Resident #s 1, 2, and 3) reviewed for comprehensive person-centered care plans. Resident #1 did not have a care plan completed after she was observed smoking a vape pen in her bathroom or after she sustained burns related to smoking while receiving oxygen therapy. Resident #2 did not have his care plan for smoking reviewed and updated when he refused to comply with the facility smoking policy. He did not sign out to smoke off facility grounds and refused to have the facility retain his smoking supplies safety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. *Food items were not properly labeled with product and expiration date in the refrigerator; and *Food items had gray, hairy substance attached. This failure could place residents who consumed food prepared by staff in the kitchen at risk of cross contamination and food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 14 residents reviewed for care plans. (Resident #'s 10, 16, 42 and 99). The facility did not develop a comprehensive care plan for Resident #10's diagnosis of PTSD. The facility did not develop a comprehensive care plan for Resident #16's psychotropic medication and did not develop a comprehensive care plan timely for hospice services. The facility did not develop a comprehensive care plan for Resident #42. Resident #99's care plan was not complete and did not reflect current diagnosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive assessment of the resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS for 1 of 14 residents reviewed for MDS assessments. (Resident # 99) The facility did not conduct an MDS assessment on Resident #99, who was admitted to the facility on [DATE]. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 14 residents reviewed for urinary catheters. (Resident #27) The facility did not properly secure and position Resident #27's urinary catheter tubing to prevent pulling, tension, or trauma per the facility policy. This failure could place residents with a urinary catheter at increased risk of urinary tract infections or trauma such as accidental removal.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 1 of 1 resident reviewed for intravenous fluids. (Resident #19) *The facility failed to administer Resident #19's intravenous antibiotic infusion in accordance with the resident's plan of care. This failure could place residents at risk of not receiving the appropriate IV care and services.