Inspection Reports for
Shady Knoll Center for Health and Rehabilitation

Violations #1 and #2 were identified as corrected as of August 3, 2025, and the Administrator was notified of the corrections on September 17, 2025.

The complaint investigation was substantiated. The facility was found to have administered the wrong dose of Methotrexate to Resident #1 on two occasions due to pharmacy mislabeling and staff failure to verify medication labels. The resident experienced no adverse effects, and corrective education was provided to staff during the survey.

The facility failed to ensure medication was administered according to physician orders and failed to ensure staff read the manufacturer label prior to administration, resulting in a medication error where a resident received double the prescribed dose of Methotrexate. The pharmacy mislabeled the medication vial, and staff did not verify the discrepancy between the pharmacy and manufacturer labels, leading to administration errors on two occasions.

The facility was found to have multiple deficiencies including failure to thoroughly investigate an allegation of mistreatment, incomplete PASRR Level II assessments, incomplete care plans for residents with smoking/vaping history, failure to support resident oral care preferences, untimely weight monitoring, delayed wound care treatment, failure to ensure resident safety with mobility equipment, failure to provide meals according to resident preferences and timely manner, serving meals at inappropriate temperatures, improper food storage and labeling, failure to refer residents to therapy after decline, failure to submit complete staffing data, and failure to respond timely to pharmacy recommendations.

The complaint investigation was triggered by allegations of mistreatment, failure to complete required assessments and care plans, medication management issues, and other regulatory compliance concerns. The facility was unable to substantiate mistreatment but was found deficient in multiple areas of care and compliance.

The facility was found deficient in multiple areas including failure to thoroughly investigate abuse allegations, incomplete PASRR Level II assessments, inadequate care planning for residents with smoking/vaping history, failure to provide assistance with oral care as preferred, untimely weight monitoring, lack of re-evaluation for mobility equipment use, delayed wound care initiation, failure to ensure smoking policy compliance, delayed pharmacist response to medication recommendations, failure to serve meals according to resident preferences and at proper temperatures, improper food storage and labeling, failure to refer residents to therapy after decline, and failure to submit required staffing data.

The visit was triggered by complaints #33780 and #39237. The report does not explicitly state substantiation status.

The report identifies multiple violations including failure to notify physicians/APRN of missed dialysis treatments, failure to maintain a dialysis communication book, incomplete and inaccurate clinical records especially related to oral care, and failure to meet staffing levels according to Connecticut Public Health Code. Corrective measures and plans to monitor compliance are outlined for each violation.

The complaint investigation found that Resident #2 missed dialysis treatments on 12/28/2022 and 12/29/2022 due to transportation issues and the facility failed to notify the physician/APRN timely. The facility also failed to maintain a dialysis communication log. Additionally, for Resident #1, the facility failed to document oral care provided or refused accurately in the clinical record.

The facility failed to notify the physician/APRN timely after missed dialysis treatments for Resident #2, failed to schedule transportation timely resulting in multiple missed dialysis sessions, failed to maintain a dialysis communication log, and failed to ensure complete and accurate clinical records for oral care provided or refused for Resident #1.

The facility failed to notify the physician of a resident's decline in oral intake, failed to ensure meal intake was properly documented, and had a non-audible call bell system on the third floor nursing unit. These deficiencies posed minimal to potential for actual harm to residents.

The investigation was complaint-driven, focusing on allegations of delayed resident assistance, medication management errors, environmental hazards, inadequate supervision, and documentation deficiencies.

The facility was found deficient in multiple areas including failure to ensure timely assistance to residents, inadequate diabetes management and notification, poor environmental maintenance, failure to notify ombudsman of hospital transfers, incomplete PASARR re-screening, improper use of non-clinical staff for 1:1 observation, failure to provide scheduled showers, expired CPR certifications, failure to monitor vital signs as ordered, inaccurate nurse staffing postings, medication reconciliation errors at discharge, unsanitary kitchen equipment, improper sanitizing solution concentration, expired emergency food supplies, and incomplete or inaccurate medical record documentation.

The facility was found to have multiple deficiencies including failure to ensure timely staff response to resident call lights, inadequate diabetes management and notification of abnormal blood glucose levels, environmental maintenance issues, failure to notify the Ombudsman of hospital transfers, incomplete PASARR re-screening, inadequate 1:1 observation by qualified staff, failure to provide scheduled showers, expired CPR certifications, incomplete vital sign monitoring, unsafe medication management at discharge, unsanitary kitchen equipment and improper sanitizing solution concentrations, inaccurate nurse staffing postings, and incomplete documentation of 1:1 behavior monitoring.

The complaint investigation included allegations of mistreatment, injury of unknown origin, verbal mistreatment, failure to notify responsible parties, failure to report abuse timely, failure to investigate allegations, and failure to maintain accurate clinical records.

The facility failed to ensure dignified care, timely notification of injuries, proper equipment maintenance, timely reporting and investigation of abuse allegations, accurate clinical documentation, safe resident transfers, timely physician orders for oxygen, and adherence to infection control protocols.