Inspection Reports for
Shady Lane Nursing Care Center
1235 S 24TH ST, MANITOWOC, WI, 54220
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 4
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations including accident prevention, medication monitoring, infection control, and COVID-19 protocols.
Findings
The facility failed to implement timely fall interventions for a resident with multiple falls, did not ensure monitoring for adverse reactions to high-risk opioid medication for another resident, and lacked an effective infection prevention and control program including Legionnaires' disease prevention related to humidifier use. Additionally, the facility did not ensure COVID-19 positive staff returned to work according to CDC guidelines and failed to implement enhanced barrier precautions for a resident with an indwelling catheter.
Deficiencies (4)
Failure to ensure timely fall interventions for resident R32 who had multiple falls between 9/4/24 and 11/12/24.
Failure to ensure monitoring interventions for adverse reactions to high-risk opioid medication for resident R8.
Failure to establish and maintain an infection prevention and control program, including lack of humidifier policy and improper COVID-19 staff return to work practices.
Failure to implement enhanced barrier precautions for resident R25 with an indwelling catheter, including lack of signage and improper catheter care by staff.
Report Facts
Residents sampled for fall intervention review: 1
Residents sampled for medication monitoring: 5
Staff signatures on Legionnaires' disease education memo: 33
Staff return to work dates not within CDC guidelines: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed regarding fall interventions, medication monitoring, infection control, and COVID-19 return to work policies |
| ADON-C | Assistant Director of Nursing | Involved in reviewing medical records and infection control policies |
| CNA-E | Observed not washing hands or wearing gown during catheter care | |
| POA-F | Power of Attorney | Reported resident symptoms and confirmed humidifier use |
| MD-D | Maintenance Director | Interviewed regarding water management and flushing procedures |
| RN-K | Registered Nurse | Interviewed regarding COVID-19 return to work policy |
| CNA-G | Interviewed about humidifier filling procedures | |
| CNA-H | Interviewed about humidifier filling and COVID-19 positive staff return to work | |
| RN-J | Registered Nurse | Interviewed about humidifier policy knowledge |
| DM-L | Dietary Manager | Interviewed about COVID-19 positive staff return to work dates |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as an annual survey of Shady Lane Nursing Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's representative of a significant change in the resident's condition.
Complaint Details
The complaint investigation found that the resident's Power of Attorney for Healthcare was not notified of the worsening and additional pressure injuries until the resident was referred to a wound clinic over a month later. The complaint was substantiated.
Findings
The facility failed to notify the activated Power of Attorney for Healthcare of a resident's worsening and new pressure injuries. The Director of Nursing believed notification occurred during a care conference, but documentation did not support this.
Deficiencies (1)
Failure to immediately notify the resident's representative of a change in condition related to pressure injuries.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON)-B | Interviewed regarding notification procedures and care conference related to resident's pressure injuries. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Shady Lane Nursing Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were unknown.
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